Duodenojejunal Flexure Research Articles

Acute Spontaneous Multiple Ileal Tuberculosis Perforation: A Case Report

A 18 years old boy presented with severe diffuse abdominal pain, constipation, abdominal distention, fever and diagnosed as a case of perforation as free gas noted under both dome of the diaphragm. After resuscitation, exploratory laparotomy was done and diagnosed as a case of multiple spontaneous leaky perforations of jejunum and ileum 25 to 30 cm from duodeno-Jejunal flexure (DJ) up to terminal ileum. Peritoneal toileting and excisional biopsy of the mesenteric lymph node were done. Operative and postoperative period were uneventful. Histopathological examination of the resected lymph node revealed granulomatous inflammation compatible with tuberculosis. Anti-tubercular therapy was started and continued for 6 months. Patient was discharged on the 12th postoperative day in a good condition. At 3 months of follow up the patient was asymptomatic and thriving well. Free perforation is one of the most feared complications of the intestinal tuberculosis. The terminal ileum is the most common site of perforation, while the majority of (90%) perforations are solitary. Bangladesh Journal of Infectious Diseases 2016;3(2):52-54

Obstructive Duodenal Lymphoma: A Case Report

Introduction: Lymphomas comprise a diverse group of neoplasms derived from B cells, T cells, or NK cells. Although GI tract is a current site for the secondry spread of non-hodgkin lymphoma, it’s involvment as the primary site is less common noticeably showing only 10% - 15%. The more lymphoid tissue is in parts of small intestine, the more incidence of lymphoma is depicted; thus, as expected, ileocecal region is the most frequent site and the duodenum remains as the most infrequent site. Case Report: An 18-year-old woman with no pervious history of any disease was admitted to the emergency room of Shohaday-e-Tajrish hospital that is a tertiary hospital in Tehran, Iran. The patient presented with weakness, nausea, and retractile vomiting. The CT scan was performed, showing that stomach and proximal of duodenum were dilated significantly and wall thickening of duodenum, 2nd and 3rd portions, was obvious. No pathological lymph node or invasion to adjacent organs was seen. The patient was explored; operation findings were dilatation of stomach and duodenum; thickening of duodenojejunal junction with 10 cm extension was mentioned. Biopsied tissue during operation showed diffuse large B cell lymphoma. Conclusions: Duodenal lymphoma is infrequent and it is rare to represent with obstruction. Thus, if there is any clinical indication and no definite diagnosis in such patient, biopsy and histopathological investigation is necessary after radiological studies.

Case of a strangulated right paraduodenal fossa hernia in a malrotated gut

We report an unusual case of a strangulated internal hernia resulting from a right paraduodenal fossa hernia (PDH) in the context of bowel malrotation. There are few documented cases of...

Management of Enterocutaneous Fistula: Outcomes in 276 Patients.

To assess the outcomes of patients with type II intestinal failure due to enterocutaneous fistulae in a tertiary referral centre over a 15 year period. Intestinal failure secondary to enterocutaneous fistula (ECF) requires multidisciplinary management at significant cost. Mortality and morbidity are high. Patients were identified from a prospectively collected database of patients requiring inpatient parenteral nutrition (1998-2013). Data collected included: demographics, mode of admission, pathological grouping and outcome. A total of 286 ECF were identified in 278 patients, mean age 64years (20-96years) with an equal gender distribution. In total, 112 fistulas developed following an emergency admission, 89 fistulas following an elective admission, and the remainder 85 were transferred from outlying district hospitals. In total, 246 ECF were as a result of previous surgery, 11 occurred following endoscopic procedures, with the remainder occurring spontaneously. All patients received parenteral nutrition (PN). Forty-seven patients overall died from sepsis/multiorgan failure. A total of 154 ECF resolved with aggressive non-operative management and 46 died prior to resolution of their fistula or surgery. 74.8% of patients with ECF proximal to the duodenal-jejunal flexure closed without surgery compared to 35.4% with disease distal to the flexure (p=0.001). Nineteen early operations were performed, with 51 patients undergoing definitive surgery. In-hospital mortality was 19.1% (53/278), with 30-day post-operative mortality from definitive surgery being 9.8% (5/51). Mortality remains high and is associated with sepsis. Fistulas proximal to the duodeno-jejunal flexure are more likely to close spontaneously. If the fistula fails to close spontaneously care is often prolonged and complex, requiring a dedicated nutrition team. In this series, spontaneous closure was more common in upper GI fistulas. Patients who are not able to be discharged in the interval between fistula formation and definitive surgery have a higher mortality risk.

Identifying intestinal malrotation on magnetic resonance examinations ordered for unrelated indications.

Anatomical imaging findings indicating normal bowel rotation can be identified on cross-sectional imaging, including magnetic resonance imaging (MRI) performed for non-related indications. The goal of our study was to assess whether non-targeted MRI can accurately assess intestinal malrotation. Four anatomical landmarks were assessed on MRIs of the chest, spine or abdomen performed from January 2006 to June 2014, on patients who also had upper gastrointestinal series (UGI) performed within 10 years of the MRI date: 1) retroperitoneal duodenum, 2) left upper quadrant duodenojejunal junction, 3) superior mesenteric artery to the left of the superior mesenteric vein, and 4) right lower quadrant cecum. Two attending radiologists, one pediatric and one abdominal radiologist, independently reviewed the MR images. The pediatric radiologist reviewed images from UGI (considered the gold standard) to determine the intestinal rotation for each case. Validation of the criteria was performed on new patients imaged through January 2016. The original cohort included 109 MRIs (15 chest, 41 spine and 53 abdomen) done on 109 patients (42% males, mean age: 10.2 years). If each of the 4 anatomical questions were answered "yes" (4-YES), specificity was 100% for each radiologist and malrotation was appropriately excluded. Using the 4-YES criteria, the pediatric radiologist excluded malrotation in 71 patients (65%) and the abdominal radiologist excluded it in 65 (60%), with concurrence for 57 patients. Validation of the 4-YES criteria in 23 new patients appropriately proved the 4-YES rule, with neither labeling the one new malrotation case 4-YES. If a radiologist can confidently answer "yes" to the four questions evaluated in this study, then intestinal rotation can be safely considered normal. Normal bowel rotation should be commented upon in MRI reports when these four anatomical locations are imaged, thus helping patients avoid unnecessary UGI and radiation exposure.

Laparoscopic Feeding Jejunostomy: A Simple Technique Using Kehr's T-Tube

Abstract Introduction: Enteral nutrition is preferred over parenteral route as it avoids septic complications associated with central venous catheter, is cost effective, and provides immunologic benefits. Percutaneous endoscopic gastrostomy is the preferred method of enteral access in most circumstances.1 However, jejunal feeds may be required for patients with gastroparesis and those at risk for aspiration. Standard techniques of laparoscopic feeding jejunostomy (FJ) require special instruments and expensive kits.2–12 A modified technique of laparoscopic FJ using an inexpensive T-tube and standard laparoscopic instruments is described. Methods: Four ports (two 10 mm and two 5 mm) are used for the procedure. A Kehr's 16F T-tube is modified by shortening the limbs. In addition, half, the diameter of the T-tube limb is excised. An enterotomy is made in the jejunum ~20 cm from the duodenojejunal flexure with a monopolar diathermy hook. The left anterior axillary port is removed and an artery forceps grasping...

Laparoscopic Resection of Gastrointestinal Stromal Tumors at the Duodenojejunal Junction

Abstract Introduction: Segmental resection of gastrointestinal stromal tumors (GISTs) at the duodenojejunal junction is technically challenging, and most cases are performed through an open techniq...

Are Intussusceptions More Common and Severe in Malrotation? - Waugh Syndrome

Waugh syndrome-The association of intussusception and malrotation is often overlooked and underdiagnosed. Malrotation need to be diagnosed preoperatively (reversal of SMA and SMV axis on doppler) or atleast looked for intraoperatively. Here is reported a case of 8 month old male child brought with complains of pain abdomen associated with fever since 4 days and passing red current like stools since last 2 days. No history of preceding diarrhoea. Parents gave history of something coming out of rectum while crying in pain since one day. Physical examination revealed mild pallor, tachycardia with distended abdomen and decreased bowel sounds. Per rectal examination showed prolapsed congested mass. Child was taken for emergency right supraumbilical transverse laparotomy and revealed mobile ascending colon and duodeno-jejunal flexure on right side of midline, with a long intussusception of terminal ileum, appendix and cecum into transverse colon, descending colon and rectum. Standard reduction was tried and it was possible to reduce it till transverse colon. Enterotomy was made into mid transverse colon to facilitate reduction of small bowel. On reduction, terminal ileum, appendix and ascending colon were not viable and was resected. In view of sepsis, ileostomy and distal stoma were made. Child had uneventful post-operative course and stoma was reversed at 6 weeks.

Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies.

AIMTo investigate the range of pathologies treated by pancreas preserving distal duodenectomy (PPDD) and present the outcome of follow-up.METHODSNeoplastic lesions of the duodenum are treated conventionally by pancreaticoduodenectomy. Lesions distal to the major papilla may be suitable for a pancreas-preserving distal duodenectomy, potentially reducing morbidity and mortality. We present our experience with this procedure. Selective intraoperative duodenoscopy assessed the relationship of the papilla to the lesion. After duodenal mobilisation and confirmation of the site of the lesion, the duodenum was transected distal to the papilla and beyond the duodenojejunal flexure and a side-to-side duodeno-jejunal anastomosis was formed. Patients were identified from a prospectively maintained database and outcomes determined from digital health records with a dataset including demographics, co-morbidities, mode of presentation, preoperative imaging and assessment, nutritional support needs, technical operative details, blood transfusion requirements, length of stay, pathology including lymph node yield and lymph node involvement, length of follow-up, complications and outcomes. Related published literature was also reviewed.RESULTSTwenty-four patients had surgery with the intent of performing PPDD from 2003 to 2016. Nineteen underwent PPDD successfully. Two patients planned for PPDD proceeded to formal pancreaticoduodenectomy (PD) while three had unresectable disease. Median post-operative follow-up was 32 mo. Pathologies resected included duodenal adenocarcinoma (n = 6), adenomas (n = 5), gastrointestinal stromal tumours (n = 4) and lipoma, bleeding duodenal diverticulum, locally advanced colonic adenocarcinoma and extrinsic compression (n = 1 each). Median postoperative length of stay (LOS) was 8 d and morbidity was low [pain and nausea/vomiting (n = 2), anastomotic stricture (n = 1), pneumonia (n = 1), and overwhelming post-splenectomy sepsis (n = 1, asplenic patient)]. PPDD was associated with a significantly shorter LOS than a contemporaneous PD series [PPDD 8 (6-14) d vs PD 11 (10-16) d, median (IQR), P = 0.026]. The 30-d mortality was zero and 16 of 19 patients are alive to date. One patient died of recurrent duodenal adenocarcinoma 18 mo postoperatively and two died of unrelated disease (at 2 mo and at 8 years respectively).CONCLUSIONPPDD is a versatile operation that can provide definitive treatment for a range of duodenal pathologies including adenocarcinoma.

State of the art therapy for gastrointestinal stromal tumor of the duodenojejunal flexure: A rare case report and review of literature

Gastrointestinal stromal tumors (GISTs) of the duodenojejunal flexure are rarely reported. Diagnosis can be elusive and their management is difficult. Definitive surgery remains the main stay of treatment for patients with localized GIST. The radical resection should be followed by adjuvant treatment only for a group of patients with adverse factors indicative of significant risk of recurrence. Our case report aims to highlight some issues related to the diagnosis and management of GISTs at this uncommon site.

Tuberculosis Unexpectedly Presented Along Gastrointestinal Tract in Surgical Ward

Little is known in our country particularly in Basra about tuberculous lesions affecting the gastrointestinal tract specifically solid and hallow organs such as liver, pancreas, stomach or intestine. Hence, this study aimed to report, describe and study these cases. The current study is retrospectively studied 12 patients who got tuberculous lesions along the gastrointestinal tract over the last 2 decades in Basra General Hospital (2 of them were gastric, 3 hepatic, 3 pancreatic, 3 small intestinal; one of them affecting duodenojejunal flexure, and lastly 1 perianal sinus ulcerating the nearby skin). All those patients underwent the required surgical operations. In all those patients, TB was diagnosed postoperatively by histopathology and all of them received anti-tuberculosis triple therapy for 6 months including INH, Rifampicin and Ethambutol. A long term scheduled follow up was done showing that all of them were improved except one elderly patient with TB pancreatitis died at early postoperative period. None of these cases effected with pulmonary tuberculosis previously or concomitantly. One case of hepatic tuberculosis had cervical and intra-abdominal lymphadenopathy. It is of interest to mention that extrapulmonary TB in solid and hallow organs of gastrointestinal tract should be considered when evaluating patients with gastrointestinal presentations and lesions such as ulcer, mass, abscess or perianal fistula in endemic areas and the potential for affecting these organs (along gastrointestinal tract) should be kept in mind and accounted for.

A new method for insertion of long intestinal tube for small bowel obstruction: Nonendoscopic over-the-wire method via short nasogastric tube.

It is often difficult to insert a long intestinal tube (LT) in patients with small bowel obstruction (SBO). We developed a novel technique for inserting an LT without endoscopy called nonendoscopic over-the-wire method via short nasogastric tube (NEWSt). We evaluated the efficacy and safety of NEWSt.We performed a retrospective study of patients who underwent LT insertion for SBO without any indications of strangulation with either NEWSt (n = 16) or endoscopy (n = 17) between November 2011 and February 2015 at our hospital. Univariate analysis was used to assess the success rate of LT placement beyond the duodenojejunal flexure, time required for the procedure, clinical outcomes, and adverse events.The success rate was 100% in both groups. Procedure time was numerically, but not statistically, shorter in the NEWSt group compared with the endoscopy group (24 ± 13 vs 30 ± 13 min; P = 0.174). There were no statistically significant differences between the 2 groups in terms of surgery rate (31% vs 12%; P = 0.225), fasting period (11.3 ± 6.3 vs 9.9 ± 4.5 days; P = 0.482), hospital stay (26.4 ± 22.1 vs 18.7 ± 7.0 days; P = 0.194), and recurrence rate (19% vs 24%; P = 1.0). No serious adverse event was observed in the NEWSt group, whereas serious aspiration pneumonia was observed in 2 patients after LT insertion in the endoscopy group.Without endoscopy, NEWSt enabled the high success rate and the short procedure time for the LT insertion. Prospective, randomized controlled trials are needed.

Occult Perforation at the Ligament of Treitz in a Patient with Cirrhosis: A Case Report and Literature Review

Abstract Background: Small intestine perforations in adults occur usually as a result of obstruction and ischemia, hernia strangulation, or trauma. When patients are found to have small intestine perforations, the location of the defect is commonly described as the distance from the ligament of Treitz, which is the suspensory ligament of the duodenum that landmarks the duodenojejunal junction. Few cases exist in which perforations occur right at the ligament of Treitz. Here, we report a rare case of an occult small intestine perforation at the ligament of Treitz in a patient with cirrhosis. Case Presentation: A 75-year-old Caucasian male with Child-Pugh class B alcoholic cirrhosis presented to the emergency department with acute abdominal pain caused by a recurrent umbilical hernia. On physical examination, he had a moderate amount of ascites and a tender mass to the right of the umbilicus. The patient was taken to the operating room (OR) for open reduction and umbilical repair. A fat-containing hernia wi...

Gastrointestinal manifestations of mitochondrial disorders: a systematic review.

Mitochondrial disorders (MIDs) due to respiratory-chain defects or nonrespiratory chain defects are usually multisystem conditions [mitochondrial multiorgan disorder syndrome (MIMODS)] affecting the central nervous system (CNS), peripheral nervous system, eyes, ears, endocrine organs, heart, kidneys, bone marrow, lungs, arteries, and also the intestinal tract. Frequent gastrointestinal (GI) manifestations of MIDs include poor appetite, gastroesophageal sphincter dysfunction, constipation, dysphagia, vomiting, gastroparesis, GI pseudo-obstruction, diarrhea, or pancreatitis and hepatopathy. Rare GI manifestations of MIDs include dry mouth, paradontosis, tracheoesophageal fistula, stenosis of the duodeno-jejunal junction, atresia or imperforate anus, liver cysts, pancreas lipomatosis, pancreatic cysts, congenital stenosis or obstruction of the GI tract, recurrent bowel perforations with intra-abdominal abscesses, postprandial abdominal pain, diverticulosis, or pneumatosis coli. Diagnosing GI involvement in MIDs is not at variance from diagnosing GI disorders due to other causes. Treatment of mitochondrial GI disease includes noninvasive or invasive measures. Therapy is usually symptomatic. Only for myo-neuro-gastro-intestinal encephalopathy is a causal therapy with autologous stem-cell transplantation available. It is concluded that GI manifestations of MIDs are more widespread than so far anticipated and that they must be recognized as early as possible to initiate appropriate diagnostic work-up and avoid any mitochondrion-toxic treatment.

Peripheral Primitive Neuro-Ectodermal Tumor - A Case Report

Peripheral primitive neuroectodermal tumours (pPNETs) are uncommon tumours constituting 1% of all soft tissue sarcomas. Duodeno jejunal junction is an uncommon location of pPNET. The clinical, radiological, histopathological and immunohistochemical characteristics of this case are described here. Multimodality treatments of such tumours include surgery, chemotherapy and radiotherapy. We present here an extremely rare case of peripheral primitive neuro-ectodermal tumour of the duodeno - jejunal junction in a 38-

Gastric outlet and duodenal/ileal obstruction due to gastric phytobezoar

We herein present the case of an 83-year-old man, ASA status III, with a fragmented gastric phytobezoar causing obstruction in different parts of the gastrointestinal tract. The initial mass was obviously in the stomach, and due to continuing coughing and vomiting the bezoar was fragmented. The apex of the bezoar moved through the deformed pyloric channel, temporarily occluding first the duodenojejunal flexure and afterwards the ileus, while the larger remnants repeatedly sealed off causing gastric outlet obstruction. At emergent laparotomy, a gastrojejunostomy was created through which both bezoars were extracted, and the operation was completed with a vagotomy. The patient had an uneventful postoperative outcome and is doing well at 12-month follow-up. Complicated bezoars require emergent surgical removal.

Surface microdialysis on small bowel serosa in monitoring of ischemia

BackgroundIschemic injury of an organ causes metabolic change from aerobic to anaerobic metabolism. It has been shown in experimental studies on the heart and liver that such conversion may be detected by conventional microdialysis probes placed intra-parenchymatously, as well as on organ surfaces, by assaying lactate, pyruvate, glucose, and glycerol in dialysate. We developed a microdialysis probe (S-μD) intended for use solely on organ surfaces. The aim of this study was to assess whether the newly developed S-μD probe could be used for detection and monitoring of small bowel ischemia. MethodsIn anesthetized normoventilated pigs, a control S-μD probe was applied on the jejunal serosa 50 cm downstream from the duodenojejunal junction (DJJ). Starting 100 cm from DJJ, a 100-cm long ischemic segment was created by division of all mesenteric vessels. S-μDs were applied at 2.5, 5, 20, and 50 cm from the starting point of ischemia by serosal sutures. A standard μD probe was placed in the abdominal cavity as a further control. Dialysate was harvested before inducing ischemia and subsequently every 20 min for 4 h. Central venous blood was drawn every hour to monitor systemic lactate, C-reactive protein, and white blood cell count. ResultsMicrodialysis lactate levels were significantly higher than baseline from 20 min on into protocol time in the ischemic segment and in the control S-μD probe. The peritoneal cavity probe showed no significant elevation. Lactate levels from the ischemic segment reached a plateau at 60 min. Courses of pyruvate, glucose, and glycerol levels were in accordance with transition from an aerobic to anaerobic metabolism in the bowel wall. No statistically significant changes in hemoglobin, white blood cell count, or lactate values in central venous blood were recorded. ConclusionsAssaying the aforementioned compounds in dialysate, harvested by the newly developed S-μD probe, allowed detection and monitoring of small bowel ischemia from 20 min on following its onset.

Spatiotemporal distribution of extracellular matrix changes during mouse duodenojejunal flexure formation.

Although gut flexures characterize gut morphology, the mechanisms underlying flexure formation remain obscure. Previously, we analyzed the mouse duodenojejunal flexure (DJF) as a model for its formation and reported asymmetric morphologies between the inner and outer bending sides of the fetal mouse DJF, implying their contribution to DJF formation. We now present the extracellular matrix (ECM) as an important factor for gut morphogenesis. We investigate ECM distribution during mouse DJF formation by histological techniques. In the intercellular space of the gut wall, high Alcian-Blue positivity for proteoglycans shifted from the outer to the inner side of the gut wall during DJF formation. Immunopositivity for fibronectin, collagen I, or pan-tenascin was higher at the inner than at the outer side. Collagen IV and laminins localized to the epithelial basement membrane. Beneath the mesothelium at the pre-formation stage, collagen IV and laminin immunopositivity showed inverse results, corresponding to the different cellular characteristics at this site. At the post-formation stage, however, laminin positivity beneath the mesothelium was the reverse of that observed during the pre-formation stage. High immunopositivity for collagen IV and laminins at the inner gut wall mesenchyme of the post-formation DJF implied a different blood vessel distribution. We conclude that ECM distribution changes spatiotemporally during mouse DJF formation, indicating ECM association with the establishment of asymmetric morphologies during this process.

The influence of nicotine in healing of small bowel anastomoses in rats: angiogenesis and miofibroblasts.

to know the effect of nicotine on angiogenesis and myofibroblast formation in anastomoses of the small bowel of rats. we randomly divided 60 Wistar rats into the groups Nicotine (N) and control (C), according to the proposed treatment. Each group was subdivided into three subgroups according to the time interval used for the evaluation (7, 14 or 28 days). The N group with 30 animals received nicotine subcutaneously at a dose of 2mg/kg body weight, diluted in 0.3ml of 0.9% saline, twice daily for 28 days prior to the operation, and for more 7, 14 or 28 days, depending on the subgroup. The C group (also 30 animals) received only saline on the same conditions and time intervals. After 28 days we carried out an end-to-end anastomosis 10cm distal to the duodenojejunal flexure in each rat. After 7, 14 or 28 days after surgery, we euthanized ten animals of each group, sent specimens of the anastomosis areas, 1cm proximal to 1cm distal, to counting of blood vessels and myofibroblasts through immunohistochemical staining by the application of monoclonal anti-factor VIII antibodies and anti-smooth muscle alpha-actin. the administration of nicotine led to the decrease in the number of blood vessels measured on the 28th postoperative day and the number of myofibroblasts measured on the seventh day following completion of the anastomoses. administration of nicotine was deleterious on angiogenesis and myofibroblast formation in rats' small intestine anastomoses. conhecer o efeito da nicotina sobre a angiogênese e formação de miofibroblastos em anastomoses do intestino delgado de ratos. sessenta ratos Wistar foram divididos de maneira aleatória em grupos Nicotina(N) e Controle (C), conforme o tratamento proposto. Cada grupo foi subdividido em três subgrupos, de acordo com o intervalo de tempo utilizado para a avaliação (7, 14 ou 28 dias). O grupo N, com 30 animais, recebeu nicotina por via subcutânea, na dose de 2mg/Kg de peso, diluída em 0,3ml de solução salina a 0,9%, em duas aplicações diárias, durante 28 dias prévios à operação e por mais 7, 14 ou 28 dias, conforme o subgrupo. O grupo C (igualmente com 30 animais) recebeu somente a solução salina nas mesmas condições e intervalos de tempo. Após 28 dias efetuou-se, em cada rato, anastomose término-terminal a 10cm da flexura duodenojejunal. Após 7, 14 ou 28 dias da cirurgia, os dez animais de cada subgrupo foram eutanasiados, sendo que as áreas anastomosadas, 1cm proximal a 1cm distal, foram encaminhadas para contagem de vasos sanguíneos e miofibroblastos, através de coloração imuno-histoquímica por aplicação dos anticorpos monoclonais antifator VIII e anti-alfa-actina muscular lisa. a administração de nicotina levou à diminuição do número de vasos sanguíneos aferidos no 28o dia pós-operatório e do número de miofibroblastos aferidos no sétimo dia após a realização das anastomoses. a administração de nicotina foi deletéria sobre a angiogênese e formação de miofibroblastos em anastomoses do intestino delgado de ratos.

Medium-Term Results of Combined Laparoscopic Sleeve Gastrectomy and Modified Jejuno-Ileal Bypass in Bariatric Surgery.

The ideal bariatric operation achieves 70-100% maintained excess weight loss, is simple with low operative risks, and maintains absorption of trace elements. Our aim was to find a bariatric procedure that achieves the above while avoiding drawbacks of current options. A standard sleeve gastrectomy was combined with a modified jejuno-ileal bypass dividing the small bowel 75cm distal to the duodeno-jejunal flexure, anastomosing it to the ileum 75cm proximal to the ileocaecal valve. Operative and follow-up data were collected prospectively between December 2004 and January 2013. One hundred sixty-eight procedures were analysed (110 female, 58 male). Mean patient age was 43years (IQR 37-47), and median preoperative body mass index (kg/m(2)) was 52 (IQR 49-59). All operations were completed laparoscopically. Excess weight loss was 78% (IQR 70-83%, 12months, n = 168), 79% (IQR 70-85%, 24months), maintained at most recent follow-up with 77% (IQR 68-84%, n = 168), and for 8year follow-up alone 75% (IQR 66-84%, n = 18). There was no operative mortality and 5.4% morbidity. A 6.5% of patients experienced transient vomiting. No symptoms of dumping or bacterial overgrowth were observed. All had normal liver enzymes. Hypocalcaemia (20.8%) and zinc deficiency (25.6%) resolved with oral supplementation. Type 2 diabetes mellitus resolved in 80.3% and improved in the remainder of patients, hypertension resolved in 92.3% and improved in the rest. Whilst currently an investigative procedure, and within the studies limitations combined sleeve gastrectomy with modified jejuno-ileal bypass is safe and effective, and evades many problems associated with current bariatric operations whilst offering maintained excess weight loss.