Duodenal Transit Bipartition: A Versatile Metabolic Procedure

This article is a narrative review with the main objective of describing the technical versatility of Duodenal Transit Bipartition (DTB). DTB represents an adaption of the classic transit bipartition concept, in which the anastomosis is shifted to a post-pyloric position in the duodenum. This technical modification preserves the pylorus and gastroduodenal continuity while creating a second pathway that directs part of the gastrointestinal content—along with bile and pancreatic secretions—early to the distal intestine. The procedure is characterized by its high technical versatility, allowing different combinations with gastric procedures (Laparoscopic Sleeve Gastrectomy, Endoscopic Sleeve Gastroplasty, or proportional Gastric Sleeve), different anastomotic techniques (manual, stapled, or magnetic), and different anastomotic locations along the duodenal segments. From a physiological standpoint, DTB probably promotes early stimulation of distal enteroendocrine L cells, potentially increasing postprandial secretion of GLP-1 and PYY. Additionally, the early arrival of bile acids to the ileum may activate the FXR-FGF19 and TGR5-GLP-1 pathways, influencing hepatic metabolism, hormonal secretion, and energy balance. It would not be appropriate to attribute the metabolic effects of DTB, or other metabolic surgical procedures, exclusively to a single mechanism. The metabolic benefit of these metabolic procedures likely derives primarily from the interaction between anatomical alterations, nutrient flow, intestinal signaling, bile acids, and secondarily from caloric reduction and weight loss. The preservation of pyloric control may reduce the risks of dumping syndrome and reactive hypoglycemia while maintaining physiological gastric emptying. This article reviews the technical aspects, physiological rationale, and clinical versatility of DTB, discussing its potential role as an adaptable metabolic procedure for patients with obesity and type 2 diabetes.