Standardization and surgical modification of sleeve gastrectomy plus jejunojejunal bypass_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

LIU Hao , TIAN Jiashi ,  DONG Guanglong

Department of General Surgery, Chinese PLA General Hospital, Beijing 100853, P. R. China;

Corresponding author：

DONG Guanglong, Email: gldong301@163.com

Keywords：

sleeve gastrectomy with jejunojejunal bypass; standardization; surgical modification; blind loop syndrome

DOI：

10.7507/1007-9424.202507084

Video：

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Objective To analyze why sleeve gastrectomy (SG) with jejunojejunal bypass (SG-JJB), despite being the second most common bariatric procedure in China, has neither been recommended in domestic and international guidelines nor endorsed by expert consensus; investigate the primary obstacles to its standardization and widespread adoption; and propose strategies leveraging China’s extensive clinical experience to refine the technique, establish standardized protocols, and address existing challenges, thereby defining its future role in metabolic surgery. Methods By systematically reviewing the evolution, current evidence profile, and distinctions of SG-JJB compared to other SG-Plus procedures, this study focused on identifying constraints hindering its adoption. Concurrently, considering the characteristics of domestic healthcare resources, we analyzed the feasibility of procedural refinements, key steps for standardization, and solutions to potential challenges, thereby facilitating the optimization and standardization of SG-JJB. Results The three key constraints hindering SG-JJB development were: risks of blind loop syndrome, uncertainty regarding optimal bypass limb length, and limited evidence on long-term efficacy. To address these issues, this study proposed leveraging China’s clinical and multi-center collaboration strengths to: conduct high-quality studies defining the impact of bypass length on outcomes, establish unified diagnostic and monitoring protocols for blind loop syndrome, and systematically collect longitudinal data to evaluate long-term efficacy, thereby informing evidence-based surgical standardization. Conclusions SG-JJB holds significant potential in Chinese bariatric-metabolic practice, yet its standardization faces challenges. Addressing concerns about blind loop syndrome, defining optimal bypass limb length, and accumulating robust long-term efficacy data are pivotal to advancing SG-JJB standardization and adoption. Leveraging domestic clinical resources through multi-center collaborations, high-quality research, and evidence-based protocol development is the essential pathway to overcoming these barriers, achieving standardized implementation, and securing recognition in authoritative guidelines.

1.	张文健, 许听, 张弘玮, 等. 减重与代谢手术术式发展历程. 发育医学电子杂志, 2023, 11(3): 236-240.
2.	Lin S, Li C, Guan W, et al. Three-year outcomes of sleeve gastrectomy plus jejunojejunal bypass: a retrospective case-matched study with sleeve gastrectomy and gastric bypass in Chinese patients with BMI ≥35 kg/m². Obes Surg, 2021, 31(8): 3525-3530.
3.	Wei Z, Ma S, Zhang Z, et al. Comparison of SADI-S versus SG in Chinese with diabetes and BMI < 35 kg/m²: a retrospective study with medium-term outcomes. Obes Surg, 2025, 35(5): 1660-1671.
4.	张鹏, 张忠涛. 中国减重代谢外科主流手术方式的科学评价. 中华消化外科杂志, 2020, 19(11): 1145-1150.
5.	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, 中国医师协会外科医师分会肥胖代谢外科综合管理专家工作组, 中国肥胖代谢外科研究协作组. 中国肥胖代谢外科数据库: 2023年度报告. 中华肥胖与代谢病电子杂志, 2024, 10(2): 73-83.
6.	Bhandari M, Fobi MAL, Buchwald JN, et al. Standardization of bariatric metabolic procedures: World consensus meeting statement. Obes Surg, 2019, 29(Suppl 4): 309-345.
7.	姚立彬, 王键, 朱孝成. 袖状胃切除术联合双通道术的前景与思考. 中国普外基础与临床杂志, 2024, 31(4): 398-402.
8.	杨珵璨, 王文越, 马帅, 等. 腹腔镜下Roux-en-Y胃旁路术: 从术式发展到精准规范. 中国普外基础与临床杂志, 2024, 31(4): 394-397.
9.	Alamo Alamo M, Sepúlveda Torres C, Zapata Perez L. Vertical isolated gastroplasty with gastro-enteral bypass: preliminary results. Obes Surg, 2006, 16(3): 353-358.
10.	de Menezes Ettinger JE, Azaro E, Mello CA, et al. Analysis of the vertical isolated gastroplasty: a new bariatric operation. Obes Surg, 2006, 16(9): 1261-1263.
11.	Alamo M, Sepúlveda M, Gellona J, et al. Sleeve gastrectomy with jejunal bypass for the treatment of type 2 diabetes mellitus in patients with body mass index <35 kg/m². A cohort study. Obes Surg, 2012, 22(7): 1097-1103.
12.	Huang CK, Mahendra R, Hsin MC, et al. Novel metabolic surgery: first Asia series and short-term results of laparoscopic proximal jejunal bypass with sleeve gastrectomy. Ann Laparosc Endosc Surg, 2016, 1: 37. doi: 10.21037/ales.2016.12.09.
13.	赵象文, 刘彦章, 梁銮盛, 等. 胃袖状切除加空肠旁路术在肥胖症的初步应用. 中华腔镜外科杂志(电子版), 2016, 9(6): 339-343.
14.	Lin S, Guan W, Yang N, et al. Short-term outcomes of sleeve gastrectomy plus jejunojejunal bypass: a retrospective comparative study with sleeve gastrectomy and Roux-en-Y gastric bypass in Chinese patients with BMI ≥ 35 kg/m². Obes Surg, 2019, 29(4): 1352-1359.
15.	Zhang H, Zhai Z, Cao K, et al. Short-term outcomes of sleeve gastrectomy plus uncut jejunojejunal bypass (SG-uncut JJB) in patients with obesity: a preliminary prospective cohort study. Langenbecks Arch Surg, 2023, 408(1): 9. doi: 10.1007/s00423-022-02742-y.
16.	Tian P, Fu J, Li M, et al. Metabolic and bariatric surgery in China: a summary of the Greater China Metabolic and Bariatric Surgery Database and comparison with other international registry databases. Diabetes Obes Metab, 2023, 25 Suppl 1: 27-33.
17.	中国医师协会外科医师分会肥胖和糖尿病外科医师委员会, 中国肥胖代谢外科研究协作组. 中国肥胖代谢外科数据库: 2022年度报告. 中华肥胖与代谢病电子杂志, 2023, 9(2): 83-91.
18.	Drenick EJ, Ament ME, Finegold SM, et al. Bypass enteropathy: an inflammatory process in the excluded segment with systemic complications. Am J Clin Nutr, 1977, 30(1): 76-89.
19.	Sepúlveda M, Alamo M, Astorga C, et al. Histologic and microbiological findings of the defunctionalized loop in sleeve gastrectomy with jejunal bypass. Surg Obes Relat Dis, 2020, 17(1): 131-138.
20.	王存川, 张鹏, 赵玉沛. 腹腔镜袖状胃切除术操作指南(2018版). 中华肥胖与代谢病电子杂志, 2018, 4(4): 196-201.
21.	王存川, 董志勇, 张鹏, 等. 腹腔镜Roux-en-Y胃旁路术规范化手术操作指南(2019版). 中华肥胖与代谢病电子杂志, 2019, 5(2): 63-69.
22.	Liang L, Gu R, Zheng R, et al. Comparative study of laparoscopic sleeve gastrectomy with or without jejunal bypass. Obes Surg, 2024, 34(8): 2888-2896.
23.	郑锐滨, 周霞, 赵象文. 超级肥胖的手术选择: 袖状胃切除术+空肠空肠旁路术?. 腹腔镜外科杂志, 2023, 28(10): 727-732.
24.	Soong TC, Almalki OM, Lee WJ, et al. Measuring the small bowel length may decrease the incidence of malnutrition after laparoscopic one-anastomosis gastric bypass with tailored bypass limb. Surg Obes Relat Dis, 2019, 15(10): 1712-1718.
25.	Zhu J. The ratio of common limb and total bowel length could be used in determination of anastomotic position in single anastomosis duodenal-ileal bypass with sleeve gastrectomy. Obes Surg, 2023, 33(5): 1598-1599.
26.	Ruiz-Tovar J, Carbajo MA, Jimenez JM, et al. Are there ideal small bowel limb lengths for one-anastomosis gastric bypass (OAGB) to obtain optimal weight loss and remission of comorbidities with minimal nutritional deficiencies?. World J Surg, 2020, 44(3): 855-862.
27.	Guan W, Lin S, Shen J, et al. Comparison of five-year physical outcomes in patients undergoing laparoscopic sleeve gastrectomy plus jejunojejunal bypass versus Roux-en-Y gastric bypass. Surg Obes Relat Dis, 2025: S1550-7289(25)00733-6. doi: 10.1016/j.soard.2025.06.008.
28.	王浪, 丁印鲁. 袖状胃切除联合空肠空肠旁路术的研究进展. 华西医学, 2025, 40(2): 305-312.
29.	韩兵. 盲襻综合征. 中级医刊, 1992, (6): 15-16.
30.	Sayadishahraki M, Mahmoudieh M, Keleidari B, et al. Using anthropometric and demographic factors to predict small bowel length to prevent malnutrition in bariatric surgery. Adv Biomed Res, 2023, 12: 209. doi: 10.4103/abr.abr_83_21.
31.	Karimi Behnagh A, Abdolhosseini M, Abdollahi A, et al. Laparoscopic small bowel length measurement: nonassociative nature of total small bowel length with anthropometric and clinical characteristics in patients undergoing bariatric surgery. Surg Obes Relat Dis, 2024, 20(9): 849-855.
32.	张帆, 吴毅, 胡昕, 等. 基于CT检查小肠三维数字化模型构建及其在减重手术前预测小肠长度的应用价值. 中华消化外科杂志, 2020, 19(4): 439-443.
33.	Slagter N, van Wilsum M, de Heide LJM, et al. Laparoscopic small bowel length measurement in bariatric surgery using a hand-over-hand technique with marked graspers: an ex vivo experiment. Obes Surg, 2022, 32(4): 1201-1208.
34.	Kaijser MA, Slagter N, de Heide LJM, et al. Measuring small bowel length in bariatric surgery: an ex vivo laparoscopic training experiment. Surg Innov, 2024, 31(4): 407-414.
35.	Wagner M, Mayer BFB, Bodenstedt S, et al. Comparison of conventional methods for bowel length measurement in laparoscopic surgery to a novel computer-assisted 3D measurement system. Obes Surg, 2021, 31(11): 4692-4700.

1. 张文健, 许听, 张弘玮, 等. 减重与代谢手术术式发展历程. 发育医学电子杂志, 2023, 11(3): 236-240.
2. Lin S, Li C, Guan W, et al. Three-year outcomes of sleeve gastrectomy plus jejunojejunal bypass: a retrospective case-matched study with sleeve gastrectomy and gastric bypass in Chinese patients with BMI ≥35 kg/m². Obes Surg, 2021, 31(8): 3525-3530.
3. Wei Z, Ma S, Zhang Z, et al. Comparison of SADI-S versus SG in Chinese with diabetes and BMI < 35 kg/m²: a retrospective study with medium-term outcomes. Obes Surg, 2025, 35(5): 1660-1671.
4. 张鹏, 张忠涛. 中国减重代谢外科主流手术方式的科学评价. 中华消化外科杂志, 2020, 19(11): 1145-1150.
5. 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, 中国医师协会外科医师分会肥胖代谢外科综合管理专家工作组, 中国肥胖代谢外科研究协作组. 中国肥胖代谢外科数据库: 2023年度报告. 中华肥胖与代谢病电子杂志, 2024, 10(2): 73-83.
6. Bhandari M, Fobi MAL, Buchwald JN, et al. Standardization of bariatric metabolic procedures: World consensus meeting statement. Obes Surg, 2019, 29(Suppl 4): 309-345.
7. 姚立彬, 王键, 朱孝成. 袖状胃切除术联合双通道术的前景与思考. 中国普外基础与临床杂志, 2024, 31(4): 398-402.
8. 杨珵璨, 王文越, 马帅, 等. 腹腔镜下Roux-en-Y胃旁路术: 从术式发展到精准规范. 中国普外基础与临床杂志, 2024, 31(4): 394-397.
9. Alamo Alamo M, Sepúlveda Torres C, Zapata Perez L. Vertical isolated gastroplasty with gastro-enteral bypass: preliminary results. Obes Surg, 2006, 16(3): 353-358.
10. de Menezes Ettinger JE, Azaro E, Mello CA, et al. Analysis of the vertical isolated gastroplasty: a new bariatric operation. Obes Surg, 2006, 16(9): 1261-1263.
11. Alamo M, Sepúlveda M, Gellona J, et al. Sleeve gastrectomy with jejunal bypass for the treatment of type 2 diabetes mellitus in patients with body mass index <35 kg/m². A cohort study. Obes Surg, 2012, 22(7): 1097-1103.
12. Huang CK, Mahendra R, Hsin MC, et al. Novel metabolic surgery: first Asia series and short-term results of laparoscopic proximal jejunal bypass with sleeve gastrectomy. Ann Laparosc Endosc Surg, 2016, 1: 37. doi: 10.21037/ales.2016.12.09.
13. 赵象文, 刘彦章, 梁銮盛, 等. 胃袖状切除加空肠旁路术在肥胖症的初步应用. 中华腔镜外科杂志(电子版), 2016, 9(6): 339-343.
14. Lin S, Guan W, Yang N, et al. Short-term outcomes of sleeve gastrectomy plus jejunojejunal bypass: a retrospective comparative study with sleeve gastrectomy and Roux-en-Y gastric bypass in Chinese patients with BMI ≥ 35 kg/m². Obes Surg, 2019, 29(4): 1352-1359.
15. Zhang H, Zhai Z, Cao K, et al. Short-term outcomes of sleeve gastrectomy plus uncut jejunojejunal bypass (SG-uncut JJB) in patients with obesity: a preliminary prospective cohort study. Langenbecks Arch Surg, 2023, 408(1): 9. doi: 10.1007/s00423-022-02742-y.
16. Tian P, Fu J, Li M, et al. Metabolic and bariatric surgery in China: a summary of the Greater China Metabolic and Bariatric Surgery Database and comparison with other international registry databases. Diabetes Obes Metab, 2023, 25 Suppl 1: 27-33.
17. 中国医师协会外科医师分会肥胖和糖尿病外科医师委员会, 中国肥胖代谢外科研究协作组. 中国肥胖代谢外科数据库: 2022年度报告. 中华肥胖与代谢病电子杂志, 2023, 9(2): 83-91.
18. Drenick EJ, Ament ME, Finegold SM, et al. Bypass enteropathy: an inflammatory process in the excluded segment with systemic complications. Am J Clin Nutr, 1977, 30(1): 76-89.
19. Sepúlveda M, Alamo M, Astorga C, et al. Histologic and microbiological findings of the defunctionalized loop in sleeve gastrectomy with jejunal bypass. Surg Obes Relat Dis, 2020, 17(1): 131-138.
20. 王存川, 张鹏, 赵玉沛. 腹腔镜袖状胃切除术操作指南(2018版). 中华肥胖与代谢病电子杂志, 2018, 4(4): 196-201.
21. 王存川, 董志勇, 张鹏, 等. 腹腔镜Roux-en-Y胃旁路术规范化手术操作指南(2019版). 中华肥胖与代谢病电子杂志, 2019, 5(2): 63-69.
22. Liang L, Gu R, Zheng R, et al. Comparative study of laparoscopic sleeve gastrectomy with or without jejunal bypass. Obes Surg, 2024, 34(8): 2888-2896.
23. 郑锐滨, 周霞, 赵象文. 超级肥胖的手术选择: 袖状胃切除术+空肠空肠旁路术?. 腹腔镜外科杂志, 2023, 28(10): 727-732.
24. Soong TC, Almalki OM, Lee WJ, et al. Measuring the small bowel length may decrease the incidence of malnutrition after laparoscopic one-anastomosis gastric bypass with tailored bypass limb. Surg Obes Relat Dis, 2019, 15(10): 1712-1718.
25. Zhu J. The ratio of common limb and total bowel length could be used in determination of anastomotic position in single anastomosis duodenal-ileal bypass with sleeve gastrectomy. Obes Surg, 2023, 33(5): 1598-1599.
26. Ruiz-Tovar J, Carbajo MA, Jimenez JM, et al. Are there ideal small bowel limb lengths for one-anastomosis gastric bypass (OAGB) to obtain optimal weight loss and remission of comorbidities with minimal nutritional deficiencies?. World J Surg, 2020, 44(3): 855-862.
27. Guan W, Lin S, Shen J, et al. Comparison of five-year physical outcomes in patients undergoing laparoscopic sleeve gastrectomy plus jejunojejunal bypass versus Roux-en-Y gastric bypass. Surg Obes Relat Dis, 2025: S1550-7289(25)00733-6. doi: 10.1016/j.soard.2025.06.008.
28. 王浪, 丁印鲁. 袖状胃切除联合空肠空肠旁路术的研究进展. 华西医学, 2025, 40(2): 305-312.
29. 韩兵. 盲襻综合征. 中级医刊, 1992, (6): 15-16.
30. Sayadishahraki M, Mahmoudieh M, Keleidari B, et al. Using anthropometric and demographic factors to predict small bowel length to prevent malnutrition in bariatric surgery. Adv Biomed Res, 2023, 12: 209. doi: 10.4103/abr.abr_83_21.
31. Karimi Behnagh A, Abdolhosseini M, Abdollahi A, et al. Laparoscopic small bowel length measurement: nonassociative nature of total small bowel length with anthropometric and clinical characteristics in patients undergoing bariatric surgery. Surg Obes Relat Dis, 2024, 20(9): 849-855.
32. 张帆, 吴毅, 胡昕, 等. 基于CT检查小肠三维数字化模型构建及其在减重手术前预测小肠长度的应用价值. 中华消化外科杂志, 2020, 19(4): 439-443.
33. Slagter N, van Wilsum M, de Heide LJM, et al. Laparoscopic small bowel length measurement in bariatric surgery using a hand-over-hand technique with marked graspers: an ex vivo experiment. Obes Surg, 2022, 32(4): 1201-1208.
34. Kaijser MA, Slagter N, de Heide LJM, et al. Measuring small bowel length in bariatric surgery: an ex vivo laparoscopic training experiment. Surg Innov, 2024, 31(4): 407-414.
35. Wagner M, Mayer BFB, Bodenstedt S, et al. Comparison of conventional methods for bowel length measurement in laparoscopic surgery to a novel computer-assisted 3D measurement system. Obes Surg, 2021, 31(11): 4692-4700.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

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