Gastro-Jejunal Ileal Interposition with Bipartition – a salvage procedure for protein-energy malnutrition
- owenhaskins
- 5 days ago
- 5 min read
Gastro-Jejunal Ileal Interposition with Bipartition (GJIB) may be a viable revision procedure for resolving protein-energy malnutrition (PEM) and related complications, without compromising the metabolic benefits of the initial surgery on diabetes resolution by decreasing the excluded bowel length percentage (Exl.B%), according to a study by researchers from Trakya University, Edirne, Turkey.
Protein-energy malnutrition and excess weight loss, related to diarrhoea or not, are serious concerns in bariatric surgery, the authors noted. The Roux-n-y (RYTB) and the one anastomotic configuration (OA) of Transit Bipartition (TB) do not anatomically exclude intestinal segments, ensuring food contact with the foregut, potentially mitigating severe protein-energy malnutrition. However, unexpected severe protein-energy malnutrition with undesired weight loss and stubborn diarrhoea was reported in patients with TB.
The researchers suggested that interposing the ileal segment into the proximal jejunum, increasing the absorptive length of the common channel, not at the expense of the alimentary limb, through a new surgical technique, the Gastrojejunal Ileal Interposition with Bipartition (GJIB), for treating severe protein-energy malnutrition or intractable diarrhoea mimicking malabsorption in TB.
Their retrospective study’s cohort included ten RYTB and OATB patients who had been converted to GJIB for intractable diarrhoea or excess weight loss associated with PEM. All patients were admitted with stubborn symptoms of PEM with fatigue, diarrhoea, increased appetite, and intractable weight loss. Patients had a typical course in the early postoperative months without signs of PEM like excessive weight loss or intractable diarrhoea.
The surgery decision for conversion was given only when diarrhoea and weight loss were intractable with constantly decreasing albumin despite medical and nutritional support. An endoscopy was performed before surgery to evaluate any presence of marginal ulcers and diagnose any complication needing a revision of the anastomoses.
Technique of Conversion of OATB to GJIB
The researchers described that conversion of OATB (shown in Figure 1A) to GJIB (shown in Figure 1E) was completed in two steps by performing two anastomoses. The afferent limb is transected proximal to GIA using a vascular (2.5 mm) cartridge (shown as (a) and (b) in Figure 1B). The transected tip of the afferent limb (shown as “b” in Figure 1C) was brought next to 30 cm, to 50 cm, to the ileocecal valve (ICV), and re-anastomosed with a vascular (2.5 mm) cartridge. The staple defect is closed with intracorporeal running sutures with polydioxanone 3/0. The alimentary limb is transected proximal to ileoileal anastomosis (shown as (c) and (d) in Figure 1D). A side-to-side isoperistaltic stapled anastomosis is fashioned with the distal end of the alimentary limb (shown as (d) in Figure 1E) and the previously marked proximal jejunum at 100 cm from Treitz. The staple opening is repaired and closed with intracorporeal running sutures with polydioxanone 3/0. The mesenteric defect is closed with interrupted stitches using polypropylene 3/0 suture. Figure 1E shows the end configuration of GJIB.
Technique of Conversion of RYTB to GJIB
The conversion of RYTB (shown in Figure 2A) to GJIB (shown in Figure 2C) was completed in one step by performing one anastomosis. The alimentary limb is transected proximal to ileoileal anastomosis (shown as (c) and (d) in Figure 2B). A side-to-side isoperistaltic stapled anastomosis was fashioned with the distal end of the alimentary limb (shown as (d) in Figure 2C) and the previously marked proximal jejunum at 100 cm from Treitz. The staple opening is repaired and closed with intracorporeal running sutures with polydioxanone 3/0. The mesenteric defects are closed with interrupted stitches using polypropylene 3/0 suture. Figure 2C shows the end configuration of GJIB.
Outcomes
Five patients underwent RYTB and five OATB. The mean age was 49.5 ± 9.19 years (33–65). Patients had fatigue despite increased appetite and excess weight loss (the mean body mass index (BMI) of 22.19 ± 1.13 kg/m2 (20.72–24.56), and the mean percentage excess BMI loss (%EBMIL) of 123.26 ± 14.85% (102.53–163.55) after initial surgery), generalized or pretibial oedema accompanying hypoalbuminemia (mean albumin of 2.7 ± 0.52 mg/dL (1.9–3.8).
No anastomotic complications were observed in preoperative endoscopy and the anastomosis was approximately 3.5–4 cm. Gastric emptying scintigraphy showed an average of 80% of food passing through the gastro-ileostomy. The mean time of conversion to GIB was 8 ± 0.71 months [2‐19] from the initial surgery, the mean duration of the operation was 67.56 ± 18.38 min, and the mean hospital stay was 4 ± 1.41 days [3‐6]. The mean follow-up period was 50.56 ± 57.28 months (1–86 months).
The bowel lengths were measured in all patients in this study. The average total bowel length was 854.5 ± 205.06 cm (735–1080), and the excluded bowel length percentage (Exl.BL%) was reduced from a median of 72.4 ± 3.18% to an average 13.4 ± 7.3% after converting to GIB configuration (p=0.005). All patients were discharged without any surgical complications or mortality.
The postoperative mean BMI increased to 28.16 ± 2.2 kg/m2 (22.7–34.3) (p=0.001), and the mean %EBMIL decreased to 79.88 ± 21.53% (28.92–133.81) (p=0.001) on the last follow-up after conversion surgery. Mean albumin levels increased to 3.9 ± 0.42 (3.1–4.5) mg/dl (p=0), and the stool frequency decreased to 2.1 ± 2.12 (0.3–5) daily (p=0). Only one patient still had pretibial oedema and fatigue at the last follow-up, which had a comparatively short follow-up of five months. All patients were diabetic before initial surgery and had a control or improvement of diabetes at the conversion time with a median HbA1c of 5.8% (6–5.4). The glycaemic control was preserved after the conversion, with median HbA1c of 5.4% (6–5.3) in the last follow-up with no significant difference.
“In conclusion, though rare, the occurrence of PEM following Transit Bipartition (TB) highlights the importance of total bowel length and its effect on nutrient absorption. While a simple reversal to sleeve gastrectomy may seem like a straightforward solution, it comes with the risk of metabolic deterioration and possible weight regain. GJIB represents a more sophisticated approach, addressing PEM while maintaining the metabolic benefits of TB,” the researchers wrote. “Future studies should further assess individualized surgical strategies based on variations in total bowel length to optimize patient outcomes. However, GJIB may be a highly safe and predictable surgical intervention that prevents malabsorption while functionally excluding the foregut and stimulating the hindgut, improving insulin resistance using multiple mechanisms.”
The findings were reported in the paper, ‘Gastro-Jejunal Ileal Interposition with Bipartition: A Salvage Procedure for Severe Protein-Energy Malnutrition After Transit Bipartition’, published in Obesity Surgery. To access this paper, please click here
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