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Loop LSG procedure

Loop duodeno-enterosomies offers new surgical options

Final aspect of the duodeno-enterostomy
No correlation found between total intestinal length and preoperative bodyweight

Loop duodeno-enterosomies with sleeve gastrectomy can be safely performed, according to a group of researchers Germany and Poland.  The study, ‘Pylorus preserving loop duodeno-enterostomy with sleeve gastrectomy - preliminary results.’ published online in BMC Surgery, concludes that this approach could ‘open new alternatives in bariatric surgery with the possibility for inter-individual adaptation’.

In the paper, the investigators from Silesian Medical University, Katowitz, Poland, the University of Freiburg and University of Schleswig-Holstein, Lübeck, Germany, present their early results of a proximal postpyloric loop duodeno-jejunostomy associated with a laparoscopic sleeve gastrectomy (LSG), compared to results of a parallel, but distal LSG with a loop duodeno-ileostomy as a two-step procedure.

They explained that bariatric surgery combines a restrictive gastric component with a rearrangement of the small intestinal passage and when reconnecting the stomach pouch to the intestine, the pylorus can either be preserved (BPD-DS) or excluded. In order to preserve the pylorus for a bypass-like procedure, in their series they combined a LSG with an end-to-side duodenojeunostomy (DJOS).

Procedural data

Sixteen patients underwent laparoscopic DIOS (distal loop duodeno-ileostomy) and DJOS operations with a mean duration of 121mins and 147mins, respectively. A total of nine patients had undergone previous weight loss surgery, mainly gastric banding. The mean latency between the sleeve and the second step DIOS operation was 17.9 months. They reported no complications specific to the duodeno-enterostomy.

The overall total intestinal length was 750.8 cm and they found no correlation between total intestinal length and preoperative bodyweight (p=0.76). The total small intestinal length in DIOS patients was significantly longer than in DJOS patients (p=0.038).


The researchers report that the mean preoperative BMI was 40.63 in DIOS and 41.60 in DJOS patients. Primary DJOS patients presented with an excess weight loss (%EWL) of 19.75% and 46.53% at one and six months.

The overall %EWL of the combined DIOS procedure was 38.31% and 49.60% one and six months. Mean weight loss through LSG alone was 31.73% with additional %EWL of 18.73% at one and 33.03% at six months following the second step operation.

A single patient did not lose any additional weight after the second step operation, despite bypassing 520cm of small intestine and clinical signs of malabsorption. Additional CT sleeve volumetry revealed a small volume of 142ml at ten months postoperatively indicating sustained restriction.

Prior to LSG, 88.9% of patients suffered from T2DM and at the time of the second-step DIOS operation, 44.4% had remained on anti-diabetic medication, with 33.3% on insulin therapy.

Three months after completion of the second step, one patient still needed anti-diabetic medication. Glycated haemoglobin levels dropped from 6.8% to 5.7% in DIOS and from 8.0% to 6.9% in DJOS patients six months after the operation.

“Although two different metabolic principles underlie the DJOS and DIOS operation, performing loop duodeno-enterostomies with sleeve gastrectomy essentially breaks down bariatric surgery into exactly these two distinct elements, leaving the possibility for individual adaptation,” the researchers conclude. “The early results of this small and heterogeneous series most importantly show no mortality and no complication related to the duodeno-enterostomy. If the DJOS and DIOS operations prove to be beneficial will have to be evaluated in randomised controlled trials.

To access the complete paper, please click here

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