A New Paradigm in Metabolic Surgery: Jejunal Bipartition

Laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) remain the most commonly performed bariatric operations worldwide; however, LSG is increasingly associated with weight regain, and the optimal revisional strategy remains debated. Bypass procedures offer potent metabolic effects but carry substantial long-term risks of micronutrient deficiencies, particularly iron and calcium, due to duodenal exclusion. Emerging evidence supports the role of both foregut and hindgut mechanisms in metabolic improvement, though neither theory fully explains the complexity of postoperative glucose homeostasis. This has stimulated interest in procedures that preserve duodenal continuity while still providing metabolic benefits.

A new concept of intestinal bipartition-jejunal bipartition associated with sleeve gastrectomy (JB + SG)-was developed to maintain complete duodenal passage while introducing a controlled hypoabsorptive component. The technique divides the ileum according to BMI-based criteria and creates two anastomoses: a proximal jejuno-ileal anastomosis at 30 cm from the Treitz angle and a distal jejuno-ileal anastomosis connecting the remaining jejunum to the terminal ileum. This configuration ensures full intestinal continuity and individualized malabsorptive effect.

JB + SG preserves duodenal transit, promoting physiological iron, calcium, and fat-soluble vitamin absorption. The dual stimulation of the proximal and terminal ileum enhances incretin release, potentially improving metabolic outcomes beyond standard LSG. Compared with RYGB, JB + SG reduces risks of marginal ulcers, dumping syndrome, severe hypoglycemia, and long-term micronutrient deficiencies. Despite requiring two anastomoses, the procedure remains technically feasible and maintains options for future revisions, including conversion to a full duodenal switch.

Jejunal bipartition represents a promising physiological alternative to traditional bariatric procedures, offering enhanced metabolic benefits with improved nutritional safety. Long-term, multicenter clinical studies are essential to validate its efficacy, durability, and safety.