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Technical refinements and advances in gastroenteric anastomosis and common-channel design for sleeve gastrectomy with transit bipartition
YAO Li-bin, WANG Jian, YU Ying-hua, HONG Jian, ZHU Xiao-cheng
Chinese Journal of Practical Surgery ›› 2026, Vol. 46 ›› Issue (9) : 1280-1285.
PDF(1313 KB)
PDF(1313 KB)
Technical refinements and advances in gastroenteric anastomosis and common-channel design for sleeve gastrectomy with transit bipartition
Sleeve gastrectomy with transit bipartition (SG-TB) creates a second route for food passage in addition to sleeve gastrectomy, preserving the physiological pyloric-duodenal and part of the proximal intestinal pathway while allowing part of the food stream to reach the distal intestine earlier. With the accumulation of clinical evidence, research has shifted from evaluating overall efficacy to the integrated optimization of sleeve configuration, gastroenteric anastomosis, and intestinal limb length. Standardized construction of a regular, unobstructed, and moderately pressurized sleeve, together with a well-perfused, tension-free, and untwisted gastroenteric anastomosis of an appropriate location and diameter, provides the basis for balancing food diversion and gastric decompression. Progressive common-channel lengthening in classic Roux-en-Y transit bipartition (RYTB), as well as comparisons between single-anastomosis sleeve ileal bypass (SASI) and single-anastomosis sleeve jejunal bypass (SASJ) within one-anastomosis transit bipartition (OATB), indicates that excessive shortening of the effective absorptive bowel may be accompanied by increased risks of malnutrition, diarrhea, and revisional surgery. Sleeve gastrectomy with Braun anastomosis transit bipartition (B-TB), sleeve gastrectomy with duodenal transit bipartition (S-DTB), and magnetic compression anastomosis offer new approaches to regulating bile flow and preserving physiological food passage, although their long-term efficacy and safety remain to be established. Future standardization of SG-TB should move beyond mechanically applying fixed lengths and toward individualized functional reconstruction based on total small bowel length, specific anastomotic configuration, common-channel or effective absorptive bowel length, and actual food-flow volume, with the aim of balancing weight loss and metabolic improvement, reflux control, nutritional safety, and the risk of revisional surgery.
obesity / metabolic and bariatric surgery / sleeve gastrectomy with transit bipartition / gastroenteric anastomosis / common channel
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中华医学会外科学分会甲状腺及代谢外科学组, 中国医师协会外科医师分会肥胖和代谢病外科专家工作组. 胃袖状切除联合双通道手术中国专家共识(2025版)[J]. 中国实用外科杂志, 2025, 45(6):611-617.DOI:10.19538/j.cjps.issn1005-2208.2025.06.02.
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To present 5-year results of sleeve gastrectomy (SG) with transit bipartition (TB) as a metabolic intervention for obesity.Recent data suggest that high glycemic index foods may lead to a hormonally hyperactive proximal gut and a hypoactivate distal gut, which are linked to metabolic syndrome. TB was designed to counterbalance these effects.A total of 1020 obese patients with body mass index (BMI) ranging from 33 to 72 Kg/m underwent SG and TB (SG + TB). TB creates a gastroileal anastomosis in the antrum after the SG; nutrient transit is maintained in the duodenum, avoiding blind loops and minimizing malabsorption. The stomach retains 2 outflow pathways. A lateral enteroanastomosis connects both segments at 80 cm proximal to the cecum.Adequate follow-up data were collected in 59.1% of patients from 4 months to 5 years. The average percent of excess BMI loss was 91%, 94%, 85%, 78%, and 74% in the first, second, third, fourth, and fifth year, respectively. Patients experienced early satiety and major improvement in presurgical comorbidities, including diabetes (86% in remission), following surgery. Two deaths occurred (0.2%). Other surgical complications occurred in 6% of patients. Signs of malabsorption were rare.SG + TB is a simple procedure that results in rapid weight loss and remission or major improvement of comorbidities. Strictly aiming at physiological correction, TB avoids prostheses, narrow anastomoses, excluded segments, and malabsorption. Weight and comorbidities are much improved. Diabetes is improved without duodenal exclusion. TB is an excellent complement to an SG.
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To compare the effects of the sleeve gastrectomy with transit bipartition (SG + TB) procedure with standard medical therapy (SMT) in mildly obese patients with type II diabetes (T2D).This is a prospective, randomized, controlled trial. Twenty male adults, ≤ 65 years old, with T2D, body mass index (BMI) > 28 kg/m and < 35 kg/m, and HbA1c level > 8% were randomized to SG + TB or to SMT. Outcomes were the remission in the metabolic and cardiovascular risk variables up to 24 months.At 24 months, SG + TB group showed a significant decrease in HbaA1c values (9.3 ± 2.1 versus 5.5 ± 1.1%, P = < 0.05) whereas SMT group maintained similar levels from baseline (8.0 ± 1.5 versus 8.3 ± 1.1%, P = NS). BMI values were lower in the SG + TB group (25.3 ± 2.8 kg/m versus 30.9 ± 2.5 kg/m; P = < 0.001). At 24 months, none patient in SG + TB group needed medications for hyperlipidemia/hypertension. HDL-cholesterol levels increased in the SG + TB group (33 ± 8 to 45 ± 15 mg/dL, P < 0.001). After 24 months, the area under the curve (AUC) of GLP1 increased and in the SG + TB group and the AUC of the GIP concentrations was lower in the SG + TB group than in the SMT. At 3 months, SG + TB group showed a marked increase in FGF19 levels (74.1 ± 45.8 to 237.3 ± 234 pg/mL; P = 0.001).SG + TB is superior to SMT and was associated with a better metabolic and cardiovascular profile.
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Metabolic surgery is an effective treatment method for glycemic control and weight loss in obese patients with type 2 diabetes mellitus (T2DM). This study aimed to present the mid-term metabolic effects and weight loss results of the patients with T2DM who underwent transit bipartition with sleeve gastrectomy (TB-SG).A total of 32 obese patients with T2DM who underwent TB-SG were included in the study. The T2DM remission status after surgery was evaluated. The postoperative glycemic variables, weight loss, lipid profile, and nutritional profile were also compared with the baseline values.At 36 months after surgery, T2DM remission occurred in 27 patients (84.3%) and the mean BMI decreased from 44.70 ± 9.34 to 29.75 ± 2.19 kg/m. The percentage of total weight loss (TWL) and excess weight loss (EWL) was 33.84% and 77.19%, respectively. The mean LDL values significantly decreased compared to baseline; however, the mean HDL did not significantly differ. No significant difference was observed regarding the mean albumin, vitamin B12, and folic acid levels.TB-SG procedure seems promising in terms of T2DM remission and weight loss with less malnutrition and vitamin deficiency in treating obese patients with T2DM.
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The "One-anastomosis transit bipartition" (OATB) is a promising emerging technique in the metabolic syndrome treatment.To demonstrate the results achieved with OATB in the first 5 years after surgery.Cross-sectional, retrospective study, with individuals undergoing primary OATB. Individuals included in the study were: ≥ 18 years, BMI ≥ 35 kg/m; and excluded smoking habits, drug dependence, inflammatory bowel diseases. The data analyzed demographic, anthropometric, surgical, clinical, and nutritional.Sixty eight participants, 75% women, average age 45.5 years and BMI 41 kg/m. Associated diseases: osteoarthritis (52.9%), hypertension (48.5%) and type 2 diabetes mellitus-T2DM (39.7%). All underwent laparoscopy, without conversions. Average operative time is 122.6 ± 31.7 min, and hospital stay is 2.2 ± 0.8 days. The common channel length 27 and 41 patients with 250 cm and 300 cm respectively. We registered no intraoperative complications, 2 (2.9%) early complications, and 14 (20.6%) late complications. In the first 6 months, 94.7% (250 cm) and 88.9% (300 cm) of the patients no longer used medication for T2DM, with no statistical difference between the two groups. The incidence of nutritional disorders at any time during follow-up: hypovitaminosis D (14.7%), folate hypovitaminosis (14.7%), elevated PTH (7.4%), hypoproteinemia (5.9%) and anemia (5.9%). We found no statistically significant difference between 250 and 300 cm common channel groups.We conclude that OATB is a safe and effective technique, demonstrating good control of T2DM and metabolic syndrome. There is a requirement to treat previous nutritional deficits. We need more long-term evidence and comparison to other surgical techniques.© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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The single anastomosis sleeve ileal bypass (SASI) procedure is a simple modification of the Roux-en-Y transit bipartition (RYTB) procedure; however, SASI risks patients with possible biliary reflux. Braun anastomosis has been proposed to fix the biliary reflux of single anastomosis procedures. This study presented our early "sleeve gastrectomy with Braun anastomosis Transit Bipartition" (B-TB) outcomes.Patients who underwent B-TB or RYTB between June 2020 and April 2021 at our hospital and have completed three months follow-up were included in this study.Ten patients with B-TB and forty patients with RYTB were included. No significant differences were observed between the B-TB and RYTB patients regarding the preoperative conditions. The B-TB procedure had significantly shorter operation time and postoperative hospitalization time than the RYTB procedure. There was no significant difference between the two groups regarding the 3-month percentage of total weight loss (B-TB vs RYTB: 19.7 ± 2.7% vs 22.2 ± 5.4%) and the postoperative complications before discharge. Preoperatively, two patients and eight patients achieved GERD-Q score ≥8 for the B-TB and RYTB group, respectively. At postoperative 3 months, those with GERD-Q score ≥8 was reduced to one patient and two patients for the B-TB and RYTB group, respectively. No patients have reported symptoms of greenish-yellow vomiting in both groups postoperatively.B-TB is an exciting procedure with potential benefits. However, as it is an investigational procedure, extra care should be maintained. Larger samples and more extended follow-up data are needed in the future.© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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朱孝成, 王键, 洪健, 等. 胃袖状切除联合双通路术对预防胃袖状切除术后胃食管反流病的价值[J]. 中国实用外科杂志, 2024, 44(8):880-884.DOI:10.19538/j.cjps.issn1005-2208.2024.08.09.
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杨建军, 董文培, 顾岩. 胃袖状切除术技术细节对术后胃食管反流病发生发展的影响及对策[J]. 中国实用外科杂志, 2024, 44(8):876-880.DOI:10.19538/j.cjps.issn1005-2208.2024.08.08.
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According to several short-term studies, single-anastomosis sleeve ileal (SASI) bypass offers similar weight loss to Roux-en-Y Gastric Bypass (RYGB) with fewer complication and better comorbidity reduction/resolution. Long-term data on this operation is lacking in the literature. The purpose of this study was to analyze the outcomes of SASI bypass up to 4 years.This study is a retrospective cohort analysis of 366 patients with morbid obesity who underwent primary SASI bypass from January 2018 to February 2022.The mean age and preoperative body mass index (BMI) were 41 years (range 22-71 years) and 43.9 ± 6.5 kg/m, respectively. Follow-up was available for 229 patients at 1-year (89%), 112 patients at 2-year (75%), 61 patients at 3-year (75%), and 35 patients at 4-year (71%). The intraoperative, short-term, and long-term complication rates were 0%, 2.5%, 4.6%, respectively. After 4 years, mean percentage excess weight loss (%EWL) was 93.3% and total weight loss (%TWL) was 41.2%. Remission of comorbidities was 93% for type 2 diabetes mellitus, 73% for hypertension, 83% for hyperlipidemia, 79% for sleep apnea, and 25% for gastroesophageal reflux disease (GERD). Biliary gastritis and ulcers are seldom. Eight patients developed de novo GERD symptoms requiring proton pump inhibitor treatment. None of the patients in our study had hypoalbuminemia or malabsorption that did not respond to increased protein intake and vitamin or mineral supplementation.SASI bypass appears to be safe, and one of the most effective bariatric procedures regarding weight loss and obesity related comorbidities. The double-outlet created in this procedure seemingly minimizes nutritional complications.© 2023. The Author(s).
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The metabolic foundation of Single Anastomosis Sleeve Ileal (SASI) bypass is based on the combination of sleeve gastrectomy with a loop gastroileal bypass. The short- and mid-term outcomes were reported in favor of adequate weight loss and safe nutritional profile. The long-term efficacy and safety remain uncertain, particularly regarding optimal limb length and anastomosis size.
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Single-anastomosis gastric bypass variants, collectively termed sleeve gastrectomy with transit bipartition (SG-TB), have emerged as simplified metabolic procedures. This meta-analysis compares the efficacy and safety of SG-TB against sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). We systematically searched multiple databases through September 2025 for comparative studies. Random-effects models were used for meta-analysis, calculating mean differences (MD) and odds ratios (OR) with 95% confidence intervals (CI). Twenty studies were included. Compared to SG, SG-TB resulted in significantly greater 1-year total weight loss (TWL MD = 3.5%, CI 1.5–5.5%) and excess weight loss (EWL MD = 10.8%, CI 8.6–13.0%). For type 2 diabetes remission, SG-TB showed a positive trend but with substantial uncertainty (OR = 2.74, CI 0.61–12.32). SG-TB demonstrated significantly higher GERD remission rates versus SG (OR = 6.90, CI 1.98–24.09). Weight loss and diabetes remission were comparable between SG-TB and RYGB. Nutritional assessment revealed generally comparable profiles, with SG-TB showing better iron/vitamin B12 preservation versus RYGB but lower vitamin D levels versus SG. SG-TB had a comparable short-term safety profile to both SG and RYGB, with no significant differences in perioperative complications, despite a longer operative time versus SG. SG-TB procedures offer superior weight loss compared to SG and achieve metabolic outcomes equivalent to RYGB, with a comparable short-term safety profile. The substantial uncertainty in diabetes remission estimates against SG warrants cautious interpretation. These findings position SG-TB as a compelling and effective surgical option for severe obesity and related metabolic disease.
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In some patients who achieved complete remission (CR) of type 2 diabetes mellitus (T2DM) after sleeve gastrectomy with transit bipartition (TB), T2DM relapses after a while. ABCD scoring predicts the likelihood of remission following TB. However, the factors affecting T2DM relapse are unknown.
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姚立彬, 于英华, 李胜利, 等. 胃袖状切除术与胃袖状切除联合双通路术术后胃食管反流病对比研究[J]. 中国实用外科杂志, 2024, 44(8):911-915.DOI:10.19538/j.cjps.issn1005-2208.2024.08.15.
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Rodrigues de Oliveira Filho J,
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SASI (single anastomosis sleeve ileal) bypass can lead to nutritional deficiencies, including disorders of iron metabolism and anemia. This study aims to evaluate the effect of SASI bypass on weight loss, anemia, and iron deficiency in patients with obesity during the follow-up period.
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After Single Anastomosis Sleeve Jejunal (SASJ) bypass, biliary reflux is a challenging postoperative issue that may require revisional intervention. Conversion to Roux-en-Y gastric bypass (RYGB) and revision to sleeve gastrectomy are two frequently used techniques. Their clinical results are assessed and contrasted in this study.
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This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.
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利益冲突 所有作者均声明不存在利益冲突
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