Main types of bariatric surgery | Sleeve gastrectomy (longitudinal gastric resection) | Статті

During the operation, ¾ or 80% of the stomach is surgically removed, including the part of the stomach where the hunger hormone ghrelin is produced.

The average rate of early complications is 4–5%.

The average mortality rate is 0.5–0.6%.

Advantages of the procedure:

Reduction of appetite.
Preservation of the physiological pathway of food passage.
Relatively technically simple to perform.
Average weight loss — 55–70% of excess body weight.
Possibility to enhance the weight loss effect in the future with bypass procedures.
Good absorption of medications and alcohol.

Disadvantages:

Requires lifelong intake of multivitamins; however, the risk of vitamin and micronutrient deficiency is significantly lower compared to other procedures.
Over time, in case of non-adherence to recommendations, gastric dilation with an increase in volume and weight regain may occur.
May not improve symptoms of reflux disease, and in approximately 30% of cases may worsen or induce gastroesophageal reflux disease (GERD).
The long-term weight loss effect is slightly lower compared to malabsorptive procedures.

SASI-S (single anastomosis sleeve ileal bypass)

In SASI-S, a sleeve gastrectomy is performed, in which 80% of the stomach is removed, leading to a reduced ability to eat and a decrease in ghrelin levels, the hormone responsible for the sensation of hunger.

Additionally, an intestinal bypass anastomosis is created, which involves connecting the lower part of the stomach (the antrum) to the distal part of the small intestine (the ileum).

This results in approximately half of the ingested food bypassing the proximal part of the small intestine, leading to reduced absorption of dietary fats, sugars, and calories.

This also decreases appetite because undigested food, when it reaches the distal small intestine, stimulates the release of intestinal hormones that reduce appetite.

The length of the small intestine bypass can vary depending on the desired weight loss.

Important nutritional micronutrients such as vitamins and minerals are still effectively absorbed through the food stream that continues to pass through the proximal small intestine.

The average rate of early complications is 5–6%.

The average mortality rate is 0.6–0.7%.

Advantages of the procedure:

Combines the advantages of sleeve gastrectomy and bypass procedures.
Weight loss is greater than with sleeve gastrectomy alone.
Lower likelihood of weight regain compared to sleeve gastrectomy.
More pronounced effect on type 2 diabetes mellitus and elevated cholesterol and lipid levels compared to sleeve gastrectomy.
Lower risk of anastomotic staple line failure, as its size is smaller than in SADI-S.
Lower risk of staple line failure along the greater curvature compared to sleeve gastrectomy, as increased pressure is not created in the gastric tube due to bypass of the pyloric sphincter.
Gastroesophageal reflux is reduced, as gastric pressure decreases and gastric emptying improves.
Lower risk of long-term nutritional deficiencies, as the partial physiological pathway of food passage through the duodenum is preserved.
Access to the bile duct is preserved for stone removal (ERCP can be performed).
Easily converted into a simple sleeve by transecting the anastomosis with a stapler.
Average weight loss — 80–90% of excess body weight.
Good absorption of medications.

Studies show that SASI-S may provide greater weight loss than standard sleeve gastrectomy or traditional Roux-en-Y gastric bypass.

Disadvantages:

Increased risk of bile reflux into the stomach.
Risk of ulcer formation at the junction between the stomach and small intestine, especially in smokers.
Requires lifelong intake of multivitamins; however, the risk of vitamin and micronutrient deficiency is significantly lower compared to other procedures.
Possibility of anastomotic ulcer development.

Gastric bypass (Roux-en-Y gastric bypass — RYGB)

During the operation, the stomach is reduced in size and connected at a certain distance to a divided small intestine to limit the absorption of food components.

The alimentary limb of the small intestine (the one connected to the small gastric pouch) is 1 meter in length.

The biliopancreatic limb of the small intestine (from the ligament of Treitz to its connection with the alimentary limb) ranges from 80 to 120 cm.

The average rate of early complications is 6–8%.

The average mortality rate is 0.6–0.8%.

Advantages of the procedure:

Average weight loss — 60–80% of excess body weight.
Highest efficacy in type 2 diabetes mellitus.
Eliminates symptoms of reflux disease.

Disadvantages:

Technically complex procedure requiring a high level of surgical expertise compared to other procedures.
Lifelong intake of multivitamin supplements is critically important.
Anastomotic ulcers may develop in smokers.
Risk of dumping syndrome occurs in 5% of patients.
Risk of gallstone disease develops in 30% of patients.
In most cases, there is no possibility to enhance the weight loss effect with an additional intervention.

Mini-gastric bypass

Mini-gastric bypass is a surgical procedure for the treatment of obesity that involves reducing the size of the stomach to facilitate early satiety and bypassing a portion of the intestine to limit food absorption.

The reduced stomach becomes similar to that in sleeve gastrectomy, but of a shorter length.

After forming the small gastric pouch, the small intestine is measured at a distance of 150–200 cm from its beginning and is anastomosed to the end of the gastric tube.

The average rate of early complications is 4–6%. The average mortality rate is 0.6–0.7%.

Advantages of the procedure:

Average weight loss — 60–80% of excess body weight.
Good efficacy in type 2 diabetes mellitus due to increased intestinal production of GLP-1, which stimulates insulin release.
Eliminates symptoms of gastroesophageal reflux disease.
Unlike RYGB, the procedure can be easily completely reversed due to the simplicity of the primary operation.
Shorter operative time and technically simpler for the surgeon compared to RYGB.
One fewer anastomosis (intestinal connection) than in RYGB, which theoretically means fewer chances of complications.

Disadvantages:

Occurrence of bile reflux, although rare.
Lifelong intake of multivitamin supplements may be required.
Possibility of anastomotic ulcer formation.
Risk of dumping syndrome in 5–10% of patients.
In most cases, there is no possibility to enhance the weight loss effect with an additional intervention.
Possible intolerance to certain foods.

SADI-S (Single Anastomosis Duodeno–Ileal Bypass with Sleeve Gastrectomy)

The SADI-S procedure consists of two stages: the first is sleeve gastrectomy with removal of approximately 80% of the stomach; the second is division of the intestine just below the stomach, after which it is reattached to a loop of intestine approximately 3 meters proximal to the ileocecal junction.

This two-stage procedure effectively diverts food from the metabolically active portion of the intestine.

In this operation, both the total length of the intestinal limb where nutrients are absorbed is reduced, and the volume of food intake is restricted, along with hormonal changes that decrease appetite, which positively affects metabolism.

Advantages of the procedure:

Average weight loss — up to 90% of excess body weight. It provides greater weight loss than sleeve gastrectomy or standard gastric bypass. This is beneficial for individuals with BMI over 50.
Has a stronger metabolic effect than sleeve gastrectomy or standard gastric bypass. This is useful for patients with poorly controlled type 2 diabetes mellitus.
Can be performed in patients who have already undergone sleeve gastrectomy.
Beneficial for individuals with weight regain or insufficient weight loss.
Reduces the risk of diarrhea and nutritional deficiencies often seen in classic biliopancreatic diversion with duodenal switch.
In this procedure, the pylorus is preserved, which regulates the rate of gastric emptying and acid delivery into the intestine and prevents bile reflux.
Reduces the likelihood of dumping syndrome, unstable blood glucose fluctuations, dietary restrictions and intolerance, as well as marginal ulcers.
Eliminates symptoms of gastroesophageal reflux disease.
The key advantage of SADI-S compared to BPD-DS (biliopancreatic diversion with duodenal switch) is that only one intestinal anastomosis is performed instead of two, which shortens operative time and reduces the risk of intestinal leakage.

Disadvantages:

Lifelong intake of multivitamin supplements may be required, as vitamin and mineral deficiencies may occur, especially without adherence to recommended daily supplementation.
Protein malabsorption may occur after SADI-S, requiring increased protein intake to meet daily requirements (~80–90 g/day).
Possible intolerance to certain foods.
Risk of gallstone disease in 50% of patients. • SADI-S is the most powerful procedure currently performed, but at the same time it is a major operation that is not easily reversible or easily correctable.

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