Diverted Ileal Interposition

30.3%

oranında insan ülkemizde obezite hastalığı ile yaşamaktadır.

49%

oranıyla kötü beslenme obezitenin en önemli nedenidir.

6000+

başarıyla tamamlanmış cerrahi operasyon deneyimi

DIVERTED ILEAL INTERPOSITION

What is Diverted Ileal Interposition?

Diverted Ileal Interposition is a very effective diabetes surgery that can be applied to patients with relatively more limited pancreatic reserve, and also to weak patients. The most important advantage is that it is effective without causing significant absorption deficiencies like other gastric bypass surgery options and can be effective without causing significant weight loss.

Diverted ileal interposition surgery aims to partially reduce food intake and to deliver the food to the last part of the small intestine (ileum) faster. Unlike the Transit Bipartition surgery, approximately 20% of the stomach (fundus region) is removed, and the middle and lower parts of the small intestines are changed (the jejunum and ileum are replaced). Connections are made(the stomach outlet is connected to the lower intestine that is brought up). To put it simply, the order of the progression of food from the stomach is normally Stomach → Duedenum → Jejenum → Ileum → Large intestine (1-2-3-4-5), postoperatively converted into stomach→ileum→jejenum→large intestine (1-4-3-5). The area within the absorption area where there is no food absorption is approximately 60-80 cm, therefore, it is considered that there is no bypassed small intestine segment. As a result, vitamin and mineral deficiencies are not expected.

It is the most effective metabolic surgery performed today. It can also be easily applied to underweight patients. It is also a surgery that should be applied to patients with progressed diabetes.

DIVERTED ILEAL INTERPOSITION

How is Diverted Ileal Interposition Surgery Performed?

The surgery is performed laparoscopically. Diverted ileal interposition surgery aims to partially reduce food intake and to deliver the food to the last part of the small intestine (ileum) faster. Unlike the Transit Bipartition surgery, approximately 20% of the stomach (fundus region) is removed, and the middle and lower parts of the small intestines are changed (the jejunum and ileum are replaced). Connections are made(the stomach outlet is connected to the lower intestine that is brought up). The area within the absorption area where there is no food absorption is approximately 60-80 cm, therefore, it is considered that there is no bypassed small intestine segment. As a result, vitamin and mineral deficiencies are not expected.

It is the most effective metabolic surgery performed today. It can also be easily applied to underweight patients. It is also a surgery that should be applied to patients with progressed diabetes. Although it may seem simple, it is a very difficult operation to perform and requires serious expertise and experience, it should not be forgotten that it can be performed in a few centers in the world and by a small number of surgeons.

DIVERTED ILEAL INTERPOSITION

What are the advantages of Diverted Ileal Interposition Surgery?

The most important advantage of this surgery is that food delivery to the area, which keeps blood sugar under control, is provided by making minimal small bowel bypass. Although the rapid access of the food to the ileal small intestine segment ensures the rapid onset of the activity, the continuity of the food flow ensures the continuity of the efficiency in sugar control.

Unlike sleeve gastrectomy or Transit Bipartition surgery, only 20% of the stomach is removed. The aim here is to reduce the production of ghrelin hormone (the hormone that stimulates the brain in case of hunger) produced in the fundus (upper part) region of the stomach, without restricting the amount of eating, and as a result, to eliminate the sudden hunger signals. The removed part has little or no effect on the amount of eating.

The structure of the muscle called the pylorus at the stomach exit is preserved, and this function, which is preserved by joining the upper intestine, prevents sudden emptying of the stomach. Thus, the food stays in the stomach for a long time and the feeling of satiety continues. Controlled passage of food from the stomach to the ileal region prevents complications such as dumping or diarrhea.

Although the placement of the small intestines has been changed, there is almost no small intestine area that does not pass food (except for the first 60-80 cm of the Duedenum). The ingested food encounters digestive enzymes in a controlled manner and at the active point, and digestion and absorption continue normally. Since the rate of passage of food to the small intestines is normal, complications such as diarrhea and dumping are not observed.

It is a very effective metabolic surgery type that can be applied to patients with relatively limited pancreatic reserve and insulin response, and also to weak patients. The most important advantage is that it is effective without causing significant absorption deficiencies like other gastric bypass surgery options and can be effective without causing significant weight loss.

Its weight loss effectiveness is short (except for the period of feeding with liquid food in the first month), so it can be applied to thin patients.

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Surgery Process

The routine approach is to evaluate the patients in the preoperative period and to take possible precautions by determining the risks. All patients should be examined in detail during the process of planning the surgery. The main purpose is to detect and treat possible deficiencies and diseases before the operation, and, if necessary, postpone the surgery.

The assessments that have to be done for this purpose, are; evaluation of the lung (such as chest X-ray, pulmonary function tests, consultation from a pulmonologist), assessment of the heart (ECG, ECHO, cardiology consultation, and further examinations like stress ECG, Holter, or angiography if necessary), psychiatric evaluations (questioning the history of drug use, substance abuse, presence of psychiatric disease, and psychiatric consultation), surgical tests (abdominopelvic ultrasonography, doppler ultrasonography, history of previous abdominal surgeries), internal medicine (non-surgical) evaluations (existence of other diseases and treatments being used, internal medicine consultation, etc.), endoscopic exploration (visual assessment of the esophagus, stomach, and small intestine with endoscopy), laboratory tests (blood work, assessment of liver functions, kidney functions, and establishing the bleeding time).

The medications used by the patients should also be taken into account (such as blood thinners, antihypertensive and antidiabetic drugs, and psychiatric drugs). During the operation, some drugs should be discontinued or replaced with other medications, and re-continued after the surgery, as soon as possible.

In the presence of additional comorbidities (like previous operations, heart attack, lung infections, neurological and psychiatric diseases, hypertension, diabetes, and obstructive sleep apnea syndrome), the patient should be checked in the relevant department, and the evaluations and suggestions of the specialist there should be taken into account.

The medications used by the patient must be evaluated, and their use, dosage, or discontinuation in pre-and post-operative time should be planned.

High-risk patients must be hospitalized and treated before the operation.

Patients who have undergone surgery are evaluated by the anesthesia team and if allowed, taken up their rooms for further follow-up after waking up. There is no need for the patient to be followed in the intensive care unit after the surg ery (except for special cases such as sleep-apnea). 6 hours after the operation, the patient can start to drink water in a controlled manner, while the patient stands up and takes mini walks. One day after the operation, the patient’s walking frequency is increased and the patient is supported with breathing exercises. Consumption of liquid foods (such as seedless soup, compote) is started in a controlled manner following the gas discharge. The drain is removed during this process. In order to observe the clinical situation and to catch possible complications, the patient stays in the hospital for a total of 3 nights and is discharged on the 4th day.

Before discharge, all details of nutrition are explained to the patient and their relatives, under the control of a dietitian, and the drugs that the patient will use and the points to be considered are explained in detail.

Postoperative diet and nutrition are explained under the control of a dietitian. Questions such as what should be eaten in the early process, at what speed and interval should it be consumed, what should not be eaten are answered.

Patients are given a 1-month diet program to follow. The main purpose here is not to weaken the patient quickly, but to ensure the safe healing of the surgical field and not to endanger the safety of the suture line with excessive-incorrect consumption.

From the first month, nutrition returns to normal in terms of consistency. In order to ensure a healthy life and controlled weight loss, foods that should not be consumed are explained in detail and the patient’s adaptation process, weight loss and blood glucose levels are monitored monthly.

The drugs that should be used in the first month after the surgery are stomach protectors, multivitamins and pain relievers if needed. These drugs are released in a controlled manner after the first month.

The drugs used in the pre-operative period are started again. In the case of regression of some weakening-related diseases (such as hypertension, hypercholesterolemia), the drugs used are left in a controlled manner in line with the knowledge and recommendation of the relevant physician.

Oral antidiabetic drugs and insulins used in patients who are suitable for surgery are not used after metabolic surgery.

Although every surgical intervention has some complications and risks, there are complications and risks specific to each surgery. What scientifically important is the occurrence and treatability of these complications.

Complications that can be seen in laparoscopic metabolic surgery are; bleeding through surgical incisions, wound problems (such as surgical site infections, and poor wound healing), specific complications (like surgical site bleeding, and leaks after the disruption of the site’s integrity), positional complications of the structural integrity of the stomach (strictures throughout the passage, twisting of the stomach around itself (torsion), etc.), post-surgical complications unrelated to the surgical site (such as lung infections, urinary tract infections, heart problems), long-term complications (weight loss faster or slower than expected, ineffective/inactive weight loss or weight gain, vitamin and mineral deficiencies).

The incidence of these complications ranges from one percent to 1 in 10 thousand to even 1 in 100 thousand. At this point, what’s important is the early diagnosis of preventable complications and the application of appropriate treatment when they occur. Likewise, identification of the causes that increase the risk of complications even before the surgery (such as the presence of other diseases, smoking, alcohol, other factors affecting wound healing, or other diseases that may increase the adverse side effects of anesthesia) and if necessary removing these risk factors first, reduces the prevalence of the complications considerably. Similarly, precautions for postoperative complications can be taken (such as early mobilization, respiratory muscle training, strict aftercare and follow-up, and early initiation of appropriate medical treatment) to ensure the process is completed without any problems.

Another important point in the postoperative period is the early detection and appropriate treatment of undesirable complications. The fact that “Early diagnosis saves lives”, which is always said in diseases such as cancer, is valid for every aspect of medicine, especially in surgical complications. Unfortunately, failure to diagnose a complication at an early stage that can be brought under control with appropriate treatment can cause the situation to worsen and may become uncontrollable and untreatable. Therefore, it is important to inform and check in with the patients at every step and to follow up with the patient closely after the surgery. It should never be forgotten that the experience and knowledge of the surgical team is the most important component in the management of surgical complications.

Frequently Asked Questions

Initially, the first requirement is to have Type 2 diabetes, and additionally to have an appropriate pancreatic reserve capacity in terms of insulin secretion. At the same time, with adequate insulin reserve, adequate release response of insulin in satiety is the feature sought. In patients with adequate insulin production and secretion, the use of oral antidiabetic pills (OAD) and/or insulin does not constitute a contraindication to surgery. The presence of additional diseases (obesity, hypertension, asthma, sleep-apnea syndrome) is not an obstacle to surgery; on the contrary, symptoms may regress after surgical intervention. Although previous abdominal surgeries make the operation difficult, it is not an obstacle for the operation to be performed in the same way. The use of sugar pills and insulin ends in the early postoperative period, the use of antihypertensive and anticholesterol drugs is terminated in the later period, and the use of sleep apnea devices such as CPAP is stopped in a controlled manner. Patients eligible for surgery should also undergo internal, cardiological, and anesthetic consultations.
In sleeve gastrectomy surgeries, the cutting of the stomach is done with a stapling system called as laparoscopic linear cutter staplers. Even if the staple line is safely closed after the procedure, bleeding may occur along the line. Scientific studies in recent years show that suturing the staple line significantly reduces the risk of bleeding in the early postoperative period. Similarly, it is known that suturing the line reduces the leakage rate. Therefore, we strongly recommend suturing the staple line in order to reduce the risk of surgical complications.
Post-operative walks are started as soon as possible. After the second week, sports such as brisk walking and swimming can be done. After the first month, weightless exercises can be started (such as pilates). As of the third month, weighted sports can be done easily (such as fitness, weighted exercises).
If the wound sites are closed subcutaneously (aesthetically) after the surgery, there is no need to remove the sutures. In patients whose stitches have to be closed normally, the stitches are removed after 12-15 days.

The period with the highest weight loss after surgery is the first month. The reasons for this are a low-calorie diet with liquid foods and the loss of excess fluid in the body, along with normal fat loss. After the balance is achieved, weight loss is parallel to the lost fat. The average weight loss seen in the first month is 5-15 kilograms.

If the person is overweight before bariatric surgery, the main goal is to lose their excess weight. Therefore, it is aimed for the patient to reach the target weight. In the following months, the average weight loss is between 1-4 kilograms per month. The increase in weight loss is related to how active the person is and how much exercise they do.

Since this surgery is usually applied to thin patients, there is no significant weight loss and sagging.
After the post-operative staple line is healed, the stomach may stretch a little, but the stomach does not enlarge.
The weight loss status of the patients after the surgery is followed up on a monthly basis by contacting them. Blood evaluations are made in the 1st, 3rd, 6th, 9th and 12th months.

Because there is not enough insulin in type 1 diabetic patients, these patients cannot benefit from surgery, so these patients should not have surgery and should continue to use insulin. In type 2 diabetes patients, patients with inadequate pancreatic reserve are not operated on.

Surgery is contraindicated to patients with severe heart failure, uncontrolled cardiovascular disease, end-stage lung disease, cancer or treated for cancer, cirrhosis in the presence of portal hypertension, uncontrolled substance or alcohol abuse, and people with severely impaired intellectual capacity.