*12.4.2 Malnutrition*

The addition of an intestinal bypass to sleeve gastrectomy has implications to the patient's nutritional status as it alters the natural absorption of nutrients. The larger stomach in sleeve-plus procedures allow more acid and intrinsic factors to have better absorption of iron, calcium, and vitamin B12 compared to an RYGB.

Comparison of SGDJB to SG alone has not shown any difference in nutritional status at one year [22, 52]. Investigational studies of SGDJB done in Chinese diabetic patients with BMI <25 kg/m2 has shown an increased incidence of becoming underweight and deficiencies in iron, vitamin B12, vitamin D and calcium [78].

In SGPJB, despite a defunctionalized intestinal segment, nutrient deficiency levels are comparable to SG. The preserved pyloric function and duodenal exclusion omitted in SGPJB also results to a lower incidence of nutritional deficiencies, diarrhea (6% vs. 21.5%), dumping syndrome (0 vs. 7.6%) and fatigue (25.3% vs. 40.5%) [61].

Postoperative supplementation of vitamins and minerals are necessary to prevent post-operative malnutrition. More studies are needed to determine the nutritional deficiency of sleeve-plus procedures to properly guide supplementation of these patients.

#### *12.4.3 Dumping syndrome*

Reconstruction of the digestive anatomy also alters the glucose metabolism which may result to dumping syndrome. This occurs in 15-76% after RYGB and may be potentially debilitating. Preservation of the pylorus in both SGDJB and SGPJB allows for a more regulated gastric emptying and a lower reported incidence of dumping syndrome at 4% and 0%, respectively [53, 61].

#### *12.4.4 Marginal ulcer*

Marginal ulcers of the gastrojejunal anastomosis of the RYGB has been reported to occur up to 12% and can lead to bleeding, perforation or stenosis. This is in contrast to low incidence reported in SGDJB Roux-en-Y technique at 0.49%, and no reported incidence in the loop technique [39, 54].

#### *12.4.5 Blind loop syndrome*

The creation of a blind loop of intestine could cause bacterial overgrowth, the so-called 'blind loop syndrome' or 'bacterial overgrowth syndrome' (BOS). *Sleeve-Plus Procedures in Asia: Duodenojejunal Bypass and Proximal Jejunal Bypass DOI: http://dx.doi.org/10.5772/intechopen.96042*

However, the SGPJB has the benefit of a blind jejunal limb without passage of food or bile, and an isoperistaltic loop [79]. This helps mitigate against the possibility of BOS. Unlike in JIB having a shorter common channel, the SGPJB enteral anastomosis has a longer common channel, in which bacterial concentration is significantly lower [60]. Incidence of BOS after SGPJB is still unknown, but intestine continuity can be easily reversed in case BOS develops.
