Abstract
Purpose
The aim of this study was to compare postoperative course of laparoscopic single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy (SADJB-SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) during a 1-year follow-up period.
Materials and Methods
Electronic medical records of all patients who underwent SADJB-SG and RYGB between March 2019 and June 2021 at a single institution were retrospectively reviewed. Surgical outcomes, weight loss, resolution of co-morbidities, episode of dumping syndrome, and marginal ulcer at endoscopy were assessed.
Results
Eighty-four patients who underwent SADJB-SG and RYGB were enrolled. One-year follow-up rate was 78.6%. There were no significant differences in operative time, estimated blood loss, length of postoperative stay, postoperative complications, readmission, or reoperation rate between SADJB-SG and RYGB. Percent of total weight loss (%TWL) was 26.9±9.3% in SADJB-SG and 29.6±7.6% in RYGB (P=0.209). Remission rates of T2DM, hypertension, dyslipidemia, and GERD were 78.3%, 63.6%, 44.4%, and 40% in SADJB-SG and 71.4%, 52.9%, 56.2%, and 12.5% in RYGB (P=0.318, P=0.480, P=0.417, and P=0.561), respectively. Episodes of dumping syndrome and marginal ulcer at endoscopy showed rates of 0% and 0% in SADJB-SG and 33.4% and 15.8% in RYGB (P=0.002 and P=0.043), respectively.
Conclusion
SADJB-SG is comparable to RYGB in terms of perioperative outcomes, weight loss, and resolution of co-morbidities. It is advantageous in terms of dumping syndrome and marginal ulcer during 1-year follow-up.
Keywords: Duodenal-jejunal bypass with sleeve gastrectomy, Gastric bypass, Dumping syndrome, Marginal ulcer, Morbid obesity
INTRODUCTION
With 650 million obesity patients worldwide [1], the demand for bariatric surgery has been ever-increasing. According to the International Federation for the Surgery of Obesity and Metabolic Disorders Global Registry of 2021, more than 500,000 bariatric operations have been conducted yearly [2]. The increase of bariatric operations lies within the introduction of novel procedures. Laparoscopic Roux-en-Y bypass (RYGB), once referred to as the gold standard bariatric surgery, retained its popularity from the mid-1970s to the early 2010s until the introduction of laparoscopic single-stage sleeve gastrectomy (LSG) in 2011 [3]. Ever since, the number of total metabolic bariatric surgeries operated has increased exponentially, from 158,000 to 256,000 cases in less than a decade [4].
Despite such notable breakthrough in the field of bariatrics, RYGB and LSG, the 2 most popular procedures, fall short in their own disadvantages. While RYGB is well-known for its effects on weight loss and reducing co-morbidities such as hypertension and type II diabetes mellitus (T2DM) [5,6], its detrimental disadvantages such as dumping syndrome, bile reflux, and marginal ulcer have been frequently evident in various studies, with reports of dumping syndromes occurring twelve times more in RYGB than in LSG (17.90% vs. 1.49%) [7,8]. LSG, despite its relatively lower complication rate than RYGB [9], also has disadvantages such as lower weight loss and remission of hypertension, T2DM and dyslipidemia [10].
A promising bariatric procedure that may overcome such complications is laparoscopic single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy (SADJB-SG). Originally designed to improve disadvantages of biliopancreatic diversion with duodenal switch, SADJB-SG has several advantages in its characteristic duodenojejunal bypass, in which elongation of the common channel may reduce complications of malnutrition. In addition, its single loop anastomosis is a procedure that requires shorter operative time and lower technical difficulty than Roux-en Y fashioned anastomosis [11]. Moreover, common complications of RYGB, such as dumping syndrome, marginal ulcer, and bile reflux, are expected to be less evident in SADJB-SG since its preservation of pylorus, acting as a gateway between the stomach and duodenum, allows slow passage of food and prevents any unwanted reflux [11]. Slowing gastric emptying is especially significant in bariatric patients who commonly suffer T2DM, as postprandial glucose excursion is determined by the pace of gastric emptying [12]. Furthermore, unlike in RYGB, the tube-like gastric remnant in SADJB-SG allows endoscopic evaluation in the future for any newly arising gastric cancer, bringing diagnostic benefit for countries with incidence of gastric cancer, such as those in East and Central Asia and Latin America [13,14].
Despite such advantages, there has been a lack of research on SADJB-SG, especially a comparative analysis of short-term and long-term complications between SADJB-SG and RYGB. Thus, this retrospective study aimed to compare postoperative course of SADJB-SG and RYGB, including efficacy in weight loss, short-term and long-term complications, and improvement of associated metabolic diseases.
MATERIALS AND METHODS
1. Patients
Electronic medical records of 84 patients who underwent SADJB-SG (41 patients) and RYGB (43 patients) at a single institution between March 2019 and June 2021 were reviewed. Patients older than 18 years with body mass index (BMI) ≥35 and those with BMI ≥30 kg/m2 and obesity related co-morbidity were included.
2. Procedures
1) SADJB-SG
Liver retraction is achieved using the sling method with a straight needle or Nathanson retractor. Devascularization of the greater curvature of the stomach (4 cm from the pylorus to the left crus of the diaphragm) is performed. Using a 38 Fr bougie placed within the stomach, a sleeve gastrectomy is performed with sequential shoots of linear stapler. The initial firing is performed with a black cartridge, followed by purple cartridges. A reinforcement suture of the staple line on the sleeved stomach is added. A stay suture is placed at the distal part of the staple line on the stomach for counter-traction and a better surgical view of the 1st portion of the duodenum. Window formation at the supra- and infra-duodenal areas and tunneling behind the duodenum using a retractor for gastric banding is performed. The duodenum is retracted anteriorly using umbilical tape to insert the stapler easily, and then the duodenum is transected using the curved tip of the tan cartridge. A greater omentum is divided in some cases to avoid tension of the anastomosis during an antecolic reconstruction. Two hundred centimeters of the jejunal loop from the ligament of Treitz is measured and fixed to the pylorus using a stay suture. Enterotomy from 1.5 cm to 2 cm at the 1st portion of the duodenum and jejunum is done, and hand-sewn anastomosis with an absorbable 3-0 barbed suture was performed in an isoperistaltic manner. A leak test is performed with a blue dye injection through the inserted bougie to check the anastomosis. An interrupted suture with non-absorbable thread is then done between the antrum and the jejunum a few centimeters proximal to the duodenojejunostomy. A continuous suture with a non-absorbable 3-0 barbed suture is then used to close Petersen defect. Finally, a Jackson-Pratt drain is inserted behind the duodenojejunal anastomosis along the staple line of the stomach.
2) RYGB
Liver retraction is performed in the same manner as SADJG-SG. The pouch is formed by sequential firing of a linear stapler around an intraluminal 38Fr bougie. The first firing is usually horizontal beginning 5 cm distal to the esophagogastric junction; subsequent firings are vertically oriented to the angle of His. One hundred centimeters of the jejunal loop from the ligament of Treitz is measured and gastrojejunostomy with a diameter of 2.5 cm is performed using a linear stapler. Entry hole is closed with a continuous suture with an absorbable 3-0 barbed suture. Petersen defect and jejunal-jejunal mesenteric defect are then closed using non-absorbable 3-0 barbed suture. Finally, the proximal jejunum of the loop-shaped gastrojejunal anastomosis is cut, and a jejunal-jejunal anastomosis is performed with the jejunum 100 cm distal to the gastrojejunal anastomosis. In this way, a biliopancreatic limb of 100 cm and a Roux limb of 100 cm are finally formed. A leak test and JP drain placement is done in the same manner as SADJB-SG.
Postoperative care and biochemical monitoring at each follow-up visit were summarized in Supplementary Table 1.
3. Study objectives
The primary objective of this study was to evaluate the safety of the 2 procedures by comparing operative time, estimated blood loss (EBL), length of postoperative stay, postoperative complication, readmission, reoperation, and mortality rate. The secondary objective was to assess the efficacy by comparing weight loss parameters (such as percentage of total weight loss [%TWL] and percent of excess BMI loss [%EBMIL]) and resolution of co-morbidities (such as T2DM, hypertension, dyslipidemia, and gastroesophageal reflux disease [GERD]) at 1-year follow-up. Episodes of dumping syndrome and marginal erosion or ulcer at endoscopy were assessed for evaluating long-term complications after bypass surgery. Laboratory data were also compared between the 2 groups before and at 2-year after surgery. All variables were described according to standardized reporting of MBS outcomes published previously [15]. Major complications include any complication that result in a prolonged hospital stay (beyond 7 days), administration of an anticoagulant, reintervention, or reoperation. Minor complications include everything else that is not included under major. Here is a summary of the standards for diabetes mellitus, hypertension, dyslipidemia, GERD, and complications (Supplementary Tables 2 and 3).
4. Statistical analysis
Categorical variables were described as counts and percentages, and continuous variables were presented as means and standard deviation after confirming that they follow a normal distribution based on Shapiro-Wilk test. Statistical analyses were performed using χ2 test and Fisher’s exact test for categorical variables and t-test and Mann–Whitney U test for continuous variables according to the test for normal distribution. A P value of less than 0.05 was considered statistically significant. All statistical analyses were performed with R software (R Foundation for Statistical Computing, Vienna, Austria; http://cran.r-project.org/).
5. Ethics statement
The Institutional Review Board of Soonchunhyang University Seoul Hospital approved the present study (registration number: SCHUH 2024-06-009). All procedures were performed in accordance with ethical standards of the responsible committees on human experimentation (institutional and national) and the Helsinki Declaration of 1964 and later versions.
RESULTS
One year follow-up rate was 78.6% (66 patients). Table 1 shows baseline characteristics of patients. There were no significant differences in sex, age, BMI, or prevalence of co-morbidities except T2DM between SADJB-SG and RYGB groups. Preoperative laboratory findings showed that hemoglobin A1c, fasting plasma glucose, and aspartate transaminase/alanine transaminase were higher in the SADJB-SG group than in the RYGB group (Table 2).
Table 1. Baseline characteristics of patients.
| Characteristics | SADJB-SG (n=41) | RYGB (n=43) | P value |
|---|---|---|---|
| Female | 28 (68.3) | 37 (86.0) | 0.092 |
| Age (years) | 38.2±10.9 | 37.6±10.9 | 0.797 |
| Body weight (kg) | 117.1±29.6 | 114.1±24.9 | 0.625 |
| BMI (kg/m2) | 42.1±9.0 | 42.0±7.7 | 0.961 |
| Hypertension | 26 (63.4) | 25 (58.1) | 0.774 |
| T2DM | 33 (80.5) | 20 (46.5) | 0.003 |
| Insulin use | 8/33 (24.2) | 2/20 (10) | 0.102 |
| DM duration | 5.0±5.4 | 3.9±6.4 | 0.500 |
| Dyslipidemia | 21 (51.2) | 22 (51.2) | 1.000 |
| GERD | 14 (34.1) | 16 (37.2) | 0.948 |
| Psychologic disease | 8 (19.5) | 14 (32.6) | 0.267 |
| F/U period (months) | 21.6±7.2 | 24.9±8.1 | 0.091 |
Values are presented as mean ± standard deviation or number (%).
SADJB-SG = single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy, RYGB = Roux-en-Y gastric bypass, BMI = body mass index, T2DM = type 2 diabetes mellitus, GERD = gastroesophageal reflux disease, F/U = follow-up.
Table 2. Preoperative laboratory findings.
| Laboratory findings | SADJB-SG (n=41) | RYGB (n=43) | P value |
|---|---|---|---|
| HbA1c (%) | 7.6±1.7 | 6.3±1.3 | <0.001 |
| FBS (mg/dL) | 176.8±65.2 | 121.7±43.0 | <0.001 |
| C-peptide (ng/mL) | 5.1±3.3 | 4.2±1.8 | 0.131 |
| Fasting Insulin (μIU/mL) | 36.0±33.6 | 33.9±30.1 | 0.770 |
| Total cholesterol (mg/dL) | 189.8±39.9 | 180.5±42.0 | 0.309 |
| Triglyceride (mg/dL) | 224.5±168.3 | 172.7±179.3 | 0.183 |
| LDL-cholesterol (mg/dL) | 116.3±34.6 | 108.5±39.1 | 0.344 |
| HDL-cholesterol (mg/dL) | 47.4±10.5 | 50.9±13.8 | 0.197 |
| AST (U/L) | 50.3±46.5 | 28.8±18.7 | 0.010 |
| ALT (U/L) | 56.8±48.1 | 35.7±28.8 | 0.020 |
| eGFR (mL/min) | 108.3±22.2 | 99.1±26.6 | 0.097 |
| Uric acid (mg/dL) | 6.0±1.2 | 6.1±1.7 | 0.685 |
| Hemoglobin (g/dL) | 14.4±1.6 | 13.6±1.8 | 0.050 |
| Ferritin (ng/mL) | 144.4±130.1 | 101.0±104.7 | 0.217 |
| Iron (μg/dL) | 86.9±33.9 | 82.8±35.0 | 0.598 |
| Vitamin B12 (pg/mL) | 587.5±294.5 | 509.1±244.4 | 0.192 |
| Albumin (g/dL) | 4.6±0.4 | 4.7±0.3 | 0.481 |
| Folate (ng/mL) | 12.6±32.5 | 6.2±2.7 | 0.228 |
| Calcium (mg/dL) | 9.8±0.4 | 9.7±0.4 | 0.510 |
| 25-(OH) Vit D3 (ng/mL) | 15.7±10.8 | 15.3±13.3 | 0.863 |
| Parathyroid hormone (pg/mL) | 57.7±33.3 | 62.4±27.2 | 0.486 |
| Vitamin B1 (nmol/L) | 203.9±62.6 | 185.0±31.6 | 0.095 |
Values are presented as mean ± standard deviation.
SADJB-SG = single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy, RYGB = Roux-en-Y gastric bypass, HbA1c = hemoglobin A1c, FBS = fasting blood sugar, LDL = low-density lipoprotein, HDL = high-density lipoprotein, AST = aspartate aminotransferase, ALT = alanine aminotransferase, eGFR = estimated glomerular filtration rate, 25-(OH) Vit D3 = magnesium, folate, vitamin B12.
Table 3 summarizes perioperative outcomes of the 2 groups. Operative time & EBL were 210.1±52.2 minutes and 23.0±12.8 cc in the SADJB-SG group and 192.7±45.8 minutes and 20.6±17.8 mL in the RYGB group, respectively, showing no statistically significant differences (P=0.108 and P=0.629). The length of postoperative stay was 3.8±2.0 days in the SADJB-SG group and 3.1 ± 1.1 days in the RYGB group (P=0.084). There were no significant differences in postoperative complications (14.6% vs. 9.3%, P=0.676), readmission (7.3% vs. 7.0%, P=1.000), or reoperation (2.4% vs. 2.3%, P=1.000) between SADJB-SG and RYGB groups.
Table 3. Perioperative outcomes.
| Outcomes | SADJB-SG (n=41) | RYGB (n=43) | P value | |
|---|---|---|---|---|
| Operative time (minutes) | 210.1±52.2 | 192.7±45.8 | 0.108 | |
| Estimated blood loss (mL) | 23.0±12.8 | 20.6±17.8 | 0.629 | |
| Postoperative hospital stay (days) | 3.8±2.0 | 3.1±1.1 | 0.084 | |
| Postoperative complication | 6 (14.6) | 4 (9.3) | 0.676 | |
| Early major | 3 (7.3) | 1 (2.3) | 0.575 | |
| Early minor | 2 (4.9) | 1 (2.3) | 0.966 | |
| Late major | 0 (0.0) | 1 (2.3) | 1.000 | |
| Late minor | 1 (2.4) | 1 (2.3) | 1.000 | |
| Readmission | 3 (7.3) | 3 (7.0) | 1.000 | |
| Reoperation | 1 (2.4) | 1 (2.3) | 1.000 | |
| Mortality | 0 (0.0) | 0 (0.0) | 1.000 | |
Values are presented as mean ± standard deviation or number (%).
SADJB-SG = single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy, RYGB = Roux-en-Y gastric bypass.
Table 4 summarizes types of complications and their treatments. There were 3 cases of early major complications in the SADJB-SG group. The 1st case was an anastomotic leak on postoperative day 1 in a patient with post-transplanted kidney status. The patient was discharged after 8 days without any problems after laparoscopic primary repair. The remaining 2 cases, 1 case of rule out (r/o) anastomotic leak and 1 case of delayed gastric emptying, were discharged without problems after conservative management. There were 2 major complications in the RYGB group. One had a r/o gastro-jejunal leak. This patient was discharged at postoperative day 8 after conservative treatment. Another one had a delayed jejunal-jejunal leak at 2 months after surgery. It was resolved through laparoscopic re-anastomosis. Of the 6 patients readmitted, 5 (83.3%) were due to various symptoms caused by dehydration.
Table 4. Types of complications and their treatments.
| Complications | SADJB-SG (n=6) | RYGB (n=4) |
|---|---|---|
| Early major | Anastomosis leak → laparoscopic primary repair on POD#1 | R/o anastomosis leak → iv antibiotics for 7 days |
| R/o anastomosis leak → iv antibiotics for 7 days | ||
| Delayed gastric emptying → NPO for 4 days | ||
| Early minor | Dehydration → fluid therapy (2 patients) | Dehydration → fluid therapy |
| Late major | Jejunal-jejunal leak at 2 months after surgery → laparoscopic re-anastomosis | |
| Late minor | Dehydration → fluid therapy | Dehydration → fluid therapy |
SADJB-SG = single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy, RYGB = Roux-en-Y gastric bypass, POD = postoperative day, R/o = rule out, iv = intravenous, NPO = nothing per oral.
Table 5 shows post-operative 1-year outcomes of patients. There was no significant difference in %TWL (26.9±9.3% vs. 29.6±7.6%, P=0.206) or %EBMIL (76.4±30.8% vs. 81.6±32.3%, P=0.505) between SADJB-SG and RYGB groups. Remission rates of T2DM, hypertension, dyslipidemia, and GERD were 78.3%, 63.6%, 44.4%, and 40% in SADJB-SG and 71.4%, 52.9%, 56.2%, and 12.5% in RYGB, respectively (P= 0.318, P=0.480, P=0.417, and P=0.561). Episodes of dumping syndrome and marginal ulcer at endoscopy had rates of 0% and 0% in SADJB-SG and 33.4% and 15.8% in RYGB (P=0.002 and P=0.043), respectively.
Table 5. Post-operative 1-year outcomes.
| Outcomes | SADJB-SG (n=33) | RYGB (n=33) | P value | ||
|---|---|---|---|---|---|
| Preoperative body weight (kg) | 118.5±30.4 | 116.2±24.7 | 0.736 | ||
| Body weight at 1 year (kg) | 85.2±17.7 | 81.7±19.3 | 0.450 | ||
| %TWL (%) | 26.9±9.3 | 29.6±7.6 | 0.206 | ||
| Preoperative BMI (kg/m2) | 42.2±9.2 | 42.5±7.6 | 0.910 | ||
| BMI at 1 year (kg/m2) | 30.3±5.3 | 29.8±6.0 | 0.717 | ||
| %EBMIL (%) | 76.4±30.8 | 81.6±32.3 | 0.505 | ||
| T2DM | 0.318 | ||||
| Remission | 18/23 (78.3) | 10/14 (71.4) | |||
| Improvement | 5/23 (21.7) | 3/14 (21.4) | |||
| Unchanged | 0/23 (0.0) | 1/14 (7.1) | |||
| Hypertension | 0.480 | ||||
| Remission | 14/22 (63.6) | 9/17 (52.9) | |||
| Improvement | 5/22 (22.7) | 3/17 (17.6) | |||
| Unchanged | 2/22 (9.1) | 5/17 (29.4) | |||
| Aggravation | 1/22 (4.5) | 0/17 (0.0) | |||
| Dyslipidemia | 0.417 | ||||
| Remission | 8/18 (44.4) | 9/16 (56.2) | |||
| Improvement | 6 (33.3) | 6 (37.5) | |||
| Unchanged | 4 (22.2) | 1 (6.2) | |||
| GERD | 4/10 (40.0) | 1/8 (12.5) | 0.561 | ||
| Remission | 4/10 (40.0) | 1/8 (12.5) | |||
| Improvement | 3 (30.0) | 5 (62.5) | |||
| Aggravation | 1 (10.0) | 1 (12.5) | |||
| De novo | 2 (20.0) | 1 (12.5) | |||
| Dumping syndrome | 0.002 | ||||
| Early | 0/31 (0.0) | 6/33 (18.2) | |||
| Late | 0/31 (0.0) | 5/33 (15.2) | |||
| Endoscopic finding | |||||
| Gastrojejunostomy | 0.043 | ||||
| Normal | 21/21 (100.0) | 14/19 (73.7) | |||
| Erosion | 0/21 (0.0) | 2/19 (10.5) | |||
| Marginal ulcer | 0/21 (0.0) | 3/19 (15.8) | |||
| Bile reflux | 1/21 (4.8) | 0/19 (0.0) | 1.000 | ||
Values are presented as mean ± standard deviation or number (%).
SADJB-SG = single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy, RYGB = Roux-en-Y gastric bypass, %TWL = percent of total weight loss, BMI = body mass index, %EBMIL = percent of excess BMI loss, T2DM = type 2 diabetes mellitus.
Table 6 demonstrates Laboratory findings at 1-year follow-up. Laboratory results at 1 year after surgery showed that the SADJB-SG group had higher fasting blood sugar than the RYGB group, but this was a smaller difference than the difference before surgery. There was no difference in vitamin B12 levels between the 2 groups before surgery, but vitamin B12 levels increased after SADJB-SG, whereas it decreased after RYGB, and there was a significant difference in levels between the 2 groups one year after surgery (785.3±460.2 vs. 392.1±170.5, P=0.001).
Table 6. Laboratory findings at 1-year follow-up.
| Laboratory findings | SADJB-SG (n=33) | RYGB (n=33) | P value |
|---|---|---|---|
| HbA1c (%) | 5.5±1.0 | 5.3±0.6 | 0.529 |
| FBS (mg/dL) | 109.6±25.2 | 97.6±10.3 | 0.046 |
| C-peptide (ng/mL) | 2.5±1.4 | 2.0±1.0 | 0.186 |
| Fasting insulin (μIU/mL) | 14.4±6.3 | 9.4±4.1 | 0.007 |
| Total cholesterol (mg/dL) | 173.0±35.3 | 166.8±32.9 | 0.568 |
| Triglyceride (mg/dL) | 118.1±66.5 | 111.8±52.9 | 0.742 |
| LDL-cholesterol (mg/dL) | 98.2±35.1 | 93.1±28.3 | 0.622 |
| HDL-cholesterol (mg/dL) | 59.7±14.9 | 60.9±14.0 | 0.795 |
| AST (U/L) | 23.0±12.4 | 22.9±6.2 | 0.959 |
| ALT (U/L) | 22.7±10.8 | 20.7±6.8 | 0.504 |
| Uric acid (mg/dL) | 5.6±1.3 | 5.4±1.7 | 0.570 |
| Hemoglobin (g/dL) | 13.6±1.7 | 12.8±2.1 | 0.205 |
| Ferritin (ng/mL) | 1,946.8±8731.1 | 57.9±51.5 | 0.322 |
| Iron (μg/dL) | 91.2±36.3 | 88.7±33.4 | 0.822 |
| Vitamin B12 (pg/mL) | 785.3±460.2 | 392.1±170.5 | 0.001 |
| Albumin (g/dL) | 4.6±0.2 | 4.5±0.2 | 0.536 |
| Folate (ng/mL) | 10.6±6.7 | 11.2±5.5 | 0.752 |
| Calcium (mg/dL) | 9.5±0.4 | 9.6±0.4 | 0.447 |
| 25-(OH) Vit D3 (ng/mL) | 21.2±11.2 | 22.0±11.6 | 0.821 |
| Parathyroid hormone (pg/mL) | 59.1±26.5 | 52.9±24.5 | 0.451 |
| Vitamin B1 (nmol/L) | 231.5±114.2 | 229.9±85.8 | 0.962 |
Values are presented as mean ± standard deviation.
SADJB-SG = single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy, RYGB = Roux-en-Y gastric bypass, HbA1c = hemoglobin A1c, FBS = fasting blood sugar, LDL = low-density lipoprotein, HDL = high-density lipoprotein, AST = aspartate aminotransferase, ALT = alanine aminotransferase, 25-(OH) Vit D3 = magnesium, folate, vitamin B12.
DISCUSSION
This is the first study that compares outcomes of SADJB-SG and RYGB in Korean patients with severe obesity. East Asians including Koreans have the following characteristics compared to other races: 1) lower BMI; 2) higher prevalence of type 2 diabetes; 3) higher prevalence of stomach cancer; 4) lower prevalence of GERD. These characteristics make SADJB-SG an important procedure that a lot of bariatric surgeons in East Asia pay attention to. This study demonstrated that SADJB-SG not only showed comparable surgical results to RYGB, the standard bypass procedure, but also significantly reduced the occurrence of dumping syndrome and marginal ulcer known to be fatal drawbacks of RYGB by preserving pyloric function, a theoretical strength. This is expected to contribute to the establishment of SADJB-SG not only in East Asia, but also around the world in the future.
Despite the above-mentioned strengths of SADJB-SG, main reasons why surgeons hesitate to perform this surgery are its high technical difficulty and long learning curve. In this study, SADJB-SG also took approximately 20 minutes longer than RYGB, consistent with results of other studies [11,16]. Additionally, in the SADJB-SG group, reoperation was performed due to anastomotic leak on the 1st day after surgery. However, considering that the author lacked surgical experience when performing SADJB-SG from the beginning of metabolic bariatric surgery and that most complications occurred were improved with conservative treatment, the author thinks that bariatric surgeons can perform this procedure safely. There has been little research on learning curve of SADJB-SG. According to a recently published study, the learning curve reaches a plateau after experiencing 25 cases [17]. Although there might be differences depending on the surgeon's experience, the author agrees with the previous finding about the plateau of the learning curve.
In this study, SADJB-SG showed comparable outcomes to RYGB not only in terms of postoperative weight loss, but also in improving obesity-related comorbidities, including T2DM. This result is consistent with several previously published studies [18,19]. In addition, theoretical advantages of SADJB-SG could be clinically proven by objectively evaluating the incidence of asymptomatic marginal ulcers through gastroscopy performed at one year after surgery. However, the fact that objective evaluation tools such as continuous glucose monitoring system or gastric emptying time were not used as tools to evaluate dumping syndrome in addition to history taking was considered a limitation of this study. In relation to this, the author is currently evaluating perioperative changes of the 2 procedures using a continuous glucose monitoring system. Results are expected to be reported soon.
Changes in laboratory parameters after surgery showed no statistically significant differences between the 2 surgery groups except for vitamin B12 and PTH. Vitamin B12 levels increased after surgery in the SADJB-SG group but decreased in the RYGB group. This might be because the gastric body, where parietal cells secreting intrinsic factor are mainly present, is more preserved in the SADJB-SG group than in the RYGB group [20,21]. However, this has not been proven. While both groups showed a decrease of calcium and an increase of vitamin D level, changes in PTH levels were different between the 2 surgical groups. Rather than showing differences in calcium or vitamin D absorption depending on the 2 procedures, it is believed that the difference will be greater depending on how diligently the supplementation is done.
This study has several limitations due to its retrospective design, a small sample size, and a short-term follow-up. To clarify results of this study, a large-scale study with a long-term follow-up should be conducted using various objective tools.
CONCLUSION
SADJB-SG is comparable to RYGB in terms of perioperative outcomes, weight loss, and resolution of co-morbidities. It is advantageous in terms of dumping syndrome and marginal ulcer during a 1-year follow-up.
Footnotes
Funding: This study was supported by the Research Program 2022 of Korean Society for Metabolic and Bariatric Surgery (KSMBS-2021-03).
Conflict of Interest: The author has no conflict of interest.
SUPPLEMENTARY MATERIALS
Summary of postoperative care and biochemical monitoring at each follow-up visit
Definitions of co-morbidities after metabolic bariatric surgery
Complications
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Summary of postoperative care and biochemical monitoring at each follow-up visit
Definitions of co-morbidities after metabolic bariatric surgery
Complications