Sleeve-Plus Procedures in Asia: Duodenojejunal Bypass and Proximal Jejunal Bypass

Laparoscopic sleeve gastrectomy (SG) is the most commonly done bariatric procedure worldwide due to its technical ease. However, the physiologic effects of this procedure have limitations on glucose homeostasis for patients with type 2 Diabetes Mellitus (T2DM). This is due to the insufficient physiologic modulations from intestinal hormones. The Roux-en-Y gastric bypass (RYGB) has been proven to have better T2DM remission than SG due to more pronounced physiologic changes from foregut and hindgut hormone modulations. However, RYGB is technically challenging to perform and is accompanied by many potential postoperative complications, especially in terms of nutrition. The addition of an intestinal bypass to SG also induces said intestinal hormone changes to enhance diabetes remission. This chapter discusses the intestinal bypass that may be added to SG as surgical options for the treatment of obesity and T2DM with focus on duodenojejunal and proximal jejunal bypass.

Impact of Metabolic Surgery on Renal Injury in Pre-Clinical Models of Diabetic Kidney Disease

<b><i>Background:</i></b> Surgical approaches to the treatment of obesity and type 2 diabetes, most notably the Roux-en-Y gastric bypass (RYGB) procedure, have been shown to be renoprotective, reducing the incidence of albuminuria and end-stage kidney disease over 15- to 20-year follow-up in patients with obesity. The tissue level effects of metabolic surgery on the diabetic kidney are not easily interrogated in clinical samples. However, elucidation of the cellular and molecular basis for the renoprotective effects of metabolic surgery is now emerging from a body of pre-clinical work in rodent models of diabetic kidney disease (DKD). <b><i>Summary:</i></b> Experimental metabolic surgery (RYGB, sleeve gastrectomy [SG], Roux-en-Y oesophagojejunostomy, and duodenojejunal bypass) exerts a pronounced albuminuria-lowering effect in rat models of DKD. Following RYGB in the Zucker diabetic fatty rat, glomerular histology is improved as demonstrated by reductions in podocyte stress, glomerulomegaly, and glomerulosclerosis. Glomerular ultrastructure improves after RYGB and after SG, manifested by quantifiable reductions in podocyte foot process effacement. The transcriptional programme underpinning these structural improvements has been characterized at the pathway level using RNA sequencing and is associated with a significant reduction in the activation of inflammatory and fibrotic responses. <b><i>Key Messages:</i></b> Experimental metabolic surgery reduces biochemical, histological, and molecular indices of DKD. These pre-clinical data support a growing interest in the potential utility of metabolic surgery as a therapeutic approach to slow renal functional decline in patients with obesity and DKD.