**10. Postoperative care and follow up**

Once the surgery has been concluded, extubated and recovered from anesthesia, the patient is then returned to the ward. Clear liquids are initiated once the patient is fully awake. Deep breathing exercises and chest physiotherapy are done. Early mobilization is encouraged and opioid analgesics are used for pain control. If there are no remarkable events, the patient is discharged and is scheduled to follow up after one week at the out-patient clinic. Diet progression is then continued as with any routine bariatric diet, with a progressive exercise program in place. Maintenance medications for diabetes and other co-morbidities are adjusted accordingly. Prophylactic proton pump inhibitors may be given. Subsequent follow-ups include dietary counseling, and is done every three months after the surgery for the first two years and then annually.

#### **11. Therapeutic outcomes**

Review of literature has reported RYGB to have better results than LSG in terms of weight loss and T2DM remission. However, complications are also reported to

be higher after RYGB [46, 47]. Up to 97% of morbidly obese SG patients have been reported to have improvement or remission of T2DM at 13 months but drops to 60.8% at five years with a recurrence rate of 13% [48]. Early reports of DJB in nonobese diabetic patients have shown improvement in sugar control albeit without remission of diabetes [49, 50]. Since there was no SG done, this suggests that weight loss is a strong factor for diabetes remission. The combination of SG with an intestinal bypass results to a synergistic combination of weight loss and sugar control.

The SGDJB was first reported by Kasama et al. in 2009, in comparison with gastric band, RYGB and SG. At one year, the excess weight loss (EWL) was similar to RYGB, and better than SG or gastric banding. Diabetes resolution of SGDJB was better than SG at 93% versus 67%. There was also resolution of dyslipidemia (100%) and hypertension (85.7%) [19]. Raj et al. published a randomized controlled trial between SGDJB and RYGB showing no statistical difference in percent EWL, diabetes remission, and resolution of hypertension and dyslipidemia [51]. Lee et al. also compared SGDJB with RYGB showing better EWL with SGDJB (80.3% vs. 63.4%) but with higher cholesterol levels than RYGB [26]. He also compared SGDJB to SG alone and reported SGDJB to have better weight loss (EWL 87.2% versus 67.5%) and diabetes remission (93% versus 87%) [52].

Kasama's group also reported the effect of SGDJB on glucose metabolism in morbid obesity with associated diabetes. Glucose monitoring showed decreasing insulin requirements on the first postoperative day to no diabetic medications on the second day. At one month, 91% of the subjects achieved an HbA1c below 7%. A meal tolerance test conducted at six months showed the subjects to have lower glucose and increased insulin area under the curve. This was reflected in the decreased requirement of oral hypoglycemic agents and insulin [53]. At one year, fasting blood sugar and HbA1c levels improved at 194 to 105 and 8.9 to 6.0, respectively, and found to be sustained up to five years with a reported remission rate of 63.6% [54].

In diabetic patients within the lower BMI range of obesity, Huang et al. reported that SGDJB resulted in a BMI drop to 22.4 from 28.4 in six months, and HbA1c levels below 7.0 without medications in 91% of the subjects [20]. On two-year follow-up, diabetes remission was found to be at 54% and glycemic control in 77% [55]. In comparison to RYGB, there were no statistical difference in the outcomes for diabetic patients with BMI less than 35 in terms of weight loss and glycemic control [56].

Studies on SGPJB have shown to the weight loss outcomes to be better than SG [57]. The EWL in one year is 96.7% and has been found to be sustained to more than 80% even after 10 years of follow-up [58]. Good glycemic control is also achieved after SGPJB. In 2016, the first Asian series was reported by Huang et al. showed 66% EWL at six months, with 66.7% of diabetic patients achieving an HbA1c less than 6 without medications [45]. A study on diabetics with BMI of <35 showed 97% of the subjects on preoperative oral hypoglycemic agents had complete remission and all of the subjects on insulin to be in partial remission [59]. When compared with RYGB, the outcomes at one and three years showed weight loss and diabetes remission to be similar, with both groups requiring less medications [60, 61].

## **12. Complications**

The overall morbidity associated with bariatric surgery complications ranges from 3.4-13% and may vary depending on the procedural type, surgical approach, patient age, BMI and co-morbidities [62–64]. Literature will show that SG has an overall complication rate lower than RYGB [65, 66]; however, potential complications associated with SG remains worrisome, including post-operative hemorrhage and staple line leak.

*Sleeve-Plus Procedures in Asia: Duodenojejunal Bypass and Proximal Jejunal Bypass DOI: http://dx.doi.org/10.5772/intechopen.96042*
