small bowel diversion

Conditions: Obesity; Type2 Diabetes

Summary: in an effort to replicate metabolic surgery's durable results in metabolic disease while minimizing its risks, two innovative methods has been created. two surgical methods to create a bowel-to-bowel anastomosis, similar to the type used in current metabolic surgeries. it be to create a jejuno-ileal, side-to-side anastomosis and jejunocolic side-to-side anastomosis. the side-to-side jejuno-ileal anastomosis and side-to-side jejunocolic anastomosis provides two routes for ingested food. the new, shorter route has a malabsorptive effect similar to that seen in roux en-y gastric bypass (rygb) and biliopancreatic diversion (bpd) - procedures which leads to weight loss. additionally, delivery of non-absorbed macronutrients to the distal ileum, or transverse colon can enhance incretin effect and improve type 2 diabetes mellitus parameters. however, the native route is also preserved, which theoretically reduces the risk of malnutrition, diarrhea, and metabolic derangements seen in other metabolic surgeries.the side-to-side jejuno-ileal anastomosis was already tested in the pilot study of the gi windows self-forming magnetic (sfm) anastomosis device for creation of an incisionless small bowel bypass for treatment of obesity and diabetes in year 2015 (15). the results of this study demonstrated the safety of this approach without serious adverse events. this non-surgical approach resulted in significant weight loss, favorable changes in insulin and incretin responses to a mixed meal and significant improvement in hba1c in t2dm (16).in summary, metabolic diseases are a growing pandemic with suboptimal clinical solutions. the surgical side-to-side jejuno-ileal anastomosis and side-to-side jejuno-colic anastomosis without gastrectomy potentially represents a new class of therapy that may produce durable clinical results generally associated with surgery while minimizing its attendant risks.

the study subjects who meet inclusion criteria and baseline procedures undergo surgery (jejunal-ileal diversion/ jejuno-colic diversion). the surgery is performed in general anesthesia with orotracheal intubation. the laparoscopic approach is used. after establishing pneumoperitoneum (insufluation of the abdominal cavity with co2) the 1th. trocar and laparoscopic camera are introduced through small incision. after visual control of abdominal cavity additional 2-3 trocars for operating instruments are introduced. the site of future anastomosis is identified (45 cm from ligament of treitz on jejunum and 45 cm for the ileocoecal junction on ileum). the anastomosis between these two parts of jejunum and ileum is created by the means of linear stapler (45 mm), the residual defect is closed by manual continuous suture. the food will be passed through intestine partially through whole small intestine and partially through the anastomosis. in the second group of patients is the anastomosis created between jejunum (45 from ligament of treitz) and transverse colon (behind the liver flexure) by means of the same technique. before the end of the operation the control of bleeding is performed. afterwards the trocars are removed under visual control. the pneumoperitoneum is released and the incisions are sutured. the subject will have follow-up clinic visits specific to the study at weeks 1, 2, and 3 and at months 1, 2, 3, 6, 12, 18, 24, 30 and 36 after the original procedure. at each clinic visit, the subject will undergo review of medical history, assessment for adverse events, physical examination (including weight and girth measurements) and blood work (e.g. glycated hemoglobin hba1c). at specific intervals, principal metabolic studies will be performed, including a mixed meal tolerance test. upper gi series radiographic studies at baseline and 14days after procedure as well as at the discretion of the principal investigator, will be performed, focusing on the patency of the anastomosis.

Eligibility criteria:
inclusion criteria: * age 18-65 years at screening; * body mass index ≥30 or ≤50kg/m2; * if subject has type 2 diabetes: fasting plasma glucose greater than 6,1 mmol/l at time of enrollment if not treated with anti-diabetic medication; * if on no diabetes medications, hemoglobin a1c between and including 6.5 and 9.0 at time of enrollment. exclusion criteria: * body mass index \>50 or \<30 kg/m2; * diagnosis of type 2 diabetes less than 6 months; * history of suspected gastrointestinal disease (for example cirrhosis, inflammatory bowel disease); * history of active malignancy (not in remission) with the exception of squamous or basal cell carcinoma of the skin; * ongoing systemic infection; * chronic pancreatitis; * chronic liver disease of any cause; * poorly controlled psychiatric disease (for example ongoing major depression, schizophrenia, borderline personality, suicidality, psychosis); * any history of an eating disorder within the past 5 years; * pre-existing severe comorbid cardio-respiratory disease (for example congestive heart failure, cardiac arrhythmia, coronary artery disease, chronic obstructive lung disease, pulmonary embolism); * uncontrolled hypertension (systolic blood preassure \> 150 mm hg or diastolic blood preassure \> 100 mm hg).

Keywords: obesity type 2 diabetes partial jejunal diversion partial jejuno-colic diversion bariatric surgery metabolic surgery side-to-side anastomosis