Functional Roux-en-Y Gastric Bypass (F-RYGB), with Preservation of Duodenal Access: Report of Two Revisional Cases of Sleeve Gastrectomy

Objective: This case report aimed to demonstrate a possible neuromuscular effect of Latarjet nerves transection or truncal vagotomy, in association with sleeve gastrectomy plus antrojejunostomy, in order to reproduce a Roux-en-Y gastric bypass (RYGB) mechanistic principles, in patients with previous Sleeve Gastrectomy (SG) who had had weight regain, with or without concomitant gastroesophageal reflux disease (GERD). Background: Sleeve gastrectomy (SG) is one of the most frequently performed bariatric operations worldwide. Nevertheless, weight regain and gastroesophageal reflux disease (GERD) have been consistently demonstrated, in association with this technique, which may require a revisional procedure. RYGB is an option in such a situation but, implies in gastrointestinal exclusions, which represents a shortcoming of this revision. Surpassing this inconvenient would be of great value for the patients. Methods: We describe herein two cases of SG revision for weight regain and GERD, with a follow-up of one year. Gastroesophageal reflux disease was evaluated by validated questionnaire, upper endoscopy, seriography, high resolution manometry (HRM) and impedance pHmetry (I-pHmetry), in the pre and postoperative periods. A re-Sleeve Gastrectomy with antrojejunal anastomosis was done in both cases, after informed consents. The Latarjet nerves were transected in one case, due to a bleeding in the left gastric vessels and a truncal vagotomy was required in the other, to appropriately treat an associated hiatal hernia. Results: In the postoperative evaluation it was observed a pyloric spasm in both cases, during seriography and endoscopy, kept until the one-year follow-up. There was unidirectional contrast flow to the gastrointestinal anastomosis, filling the jejunal limb, in radiologic contrast study. No contrast passed through the pylorus. Nonetheless, the duodenum was kept endoscopically accessible. In the one-year evaluation, weight loss was adequate and GERD resolution was obtained in both cases, confirmed by endoscopic and functional esophageal assessment, together with symptoms questionnaire. Conclusion: The association of Latarjet nerves sectioning or truncal vagotomy with re-sleeve gastrectomy plus gastrointestinal anastomosis (antrojejunal), in a revision for a failed sleeve, can represent a technical approach, to reproduce RYGB results, without exclusions and with duodenum endoscopic accessibility maintenance. It maybe could be applied for primary surgeries. Additional studies are necessary to confirm this hypothesis.

Pyloric Sympathectomy: A Novel Way to Get Pylorus Relaxation? Report of Two Bariatric Cases

Objective: This case report aimed to demonstrate a possible neuromuscular effect of pyloric sympathectomy on the pylorus motility, leading to its permanent relaxation, observed in two bariatric surgical cases, one primary and the other, revisional. Background: Pyloric sphincter is a physiological barrier to free gastric emptying. In sleeve gastrectomy and in Roux-en-Y gastric bypass revisions, that put the remnant stomach in transit, the pylorus can contribute to generate a high intragastric pressure, which could lead to acute gastric fistulas and/or chronic gastroesophageal reflux disease. The possibility of functionally relaxing the pylorus, promoting intragastric pressure reduction, could represent a protective maneuver against these complications. Methods: We describe herein a surgical maneuver applied in two cases of bariatric surgeries, with the intention of facilitating antrum-duodenal region exposure, in a sleeve gastrectomy and in a Roux-en-Y gastric bypass conversion to SADI-S. For this, a ligation of terminal peripyloric vessels was done, allowing a passage of a tape, which surrounded the pylorus, for its traction. In both cases, 30-day and 1-year endoscopic evaluations were done, to assess esophagitis signs, anastomosis healing and anatomical pouch aspect. A clinical evaluation was also done, to assess gastroesophageal symptoms (validated questionnaire). Results: In the postoperative endoscopic evaluations, no esophagitis were observed in any case and the gastric pouches had normal aspect, with the expected anatomical findings, compatible with the surgeries performed. The anastomosis healed without problems, in the revisional case. Interestingly, in both cases, it was observed a complete pyloric sphincter relaxation, which lasted until 1-year endoscopic evaluation. There were no fistulas, nor esophagitis in any of these cases. Clinically, there were no symptoms of gastroesophageal reflux disease (validated questionnaire). Conclusion: The observation of a pyloric durable atomy, that followed peripyloric dissection and vessels ligation (arterial branches), with its concomitant sympathectomy, can represent a new way of decompressing gastric chamber, either in primary or revisional bariatric surgeries. This maneuver can be protective against acute fistulas and gastroesophageal disease. Additional studies are necessary to confirm this hypothesis.

Sleeve Gastrectomy with Duodenal Transit Bipartition (S-DTB): Preliminary Results and Technical Aspects of Its Metabolic Structure

Obesity is a significant and escalating health issue both in Brazil and globally, with over 650 million overweight adults worldwide. The treatment of obesity can be performed clinically, endoscopically or surgically;surgical treatment proves to be safe and more effective in terms of weight loss and long-term maintenance. Objective: This study aimed to monitor the progress of weight loss and comorbidity control in patients undergoing sleeve gastrectomy with duodenal bipartition. Methods: This pilot project involved 8 patients divided into 2 arms. In the first arm, patients underwent sleeve gastrectomy with Roux-en-Y duodenoileal transit bipartition (S-RYDITB), while in the second arm, patients underwent sleeve gastrectomy with Roux-en-Y duodenojejunal transit bipartition (S-RYDJTB). Both procedures involved Roux-en-Y reconstruction without duodenal exclusion. In S-RYDITB, the duodenal-ileal anastomosis was performed 300 cm from the ileocecal valve (ICV), creating a 250 cm common channel and a 50 cm alimentary channel. In S-RYDJTB, a biliopancreatic loop was created 200 cm from the angle of Treitz, with a 1 m alimentary channel. Results: Five patients underwent the procedures, with one undergoing S-RYDITB and four undergoing S-RYDJTB. No adverse events such as hospitalizations, readmissions, reoperations, fistulas, bleeding, pulmonary embolism, diarrhea, dumping syndrome, or hypoglycemia occurred during the study period. The mean length of hospital stay was 2 days. The average BMI decreased from 37.27 kg/m2 preoperatively to 29.48 kg/m2 after 6 months. The significant percentage of weight loss was 21.22%, with excess weight loss of 63.6%. Ninety-five percent remission of comorbidities, including hypercholesterolemia, hypertriglyceridemia, diabetes, hypertension, steatosis, and pre-diabetes. Two patients underwent sleeve gastrectomy with duodenal bipartition using a single anastomosis. Conclusion: Duodenal switch surgery has gained worldwide recognition for its safety and efficacy in treating obesity and its associated comorbidities. In efforts to maintain the positive outcomes of the classic technique while minimizing adverse effects such as malnutrition and diarrhea, modifications to the original procedure have been proposed. Among these adaptations, Sleeve gastrectomy with bipartition of duodenal transit (S-DTB) emerges as a promising variant, offering alternative strategies to optimize patients’ nutritional safety while preserving endoscopic access to the duodenum. Initial results of S-DTB, whether performed in Roux-en-Y or single anastomosis (loop) configuration without intestinal exclusions, demonstrate the procedure’s safety and effectiveness in managing obesity and its comorbidities.

SADI-S with Extended Duodeno-Bulb Preservation: Case Report

Obesity has been growing in Brazil and in the world. It is reaching epidemic proportions, and bariatric surgery is the most effective treatment for patients with this disease. Among the procedures described in the literature, ileal surgeries such as biliopancreatic diversion with duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) present better long-term results in terms of weight loss and comorbidities control. However, there are concerns regarding long term nutritional problems with these procedures. In this case report the aim is to demonstrate the technical feasibility of preserving an extended duodenal bulb segment, in the SADIS-S procedure, when there are difficulties in dissecting the retrobulbar region, as occurred here, due to fibrosis in this area. This assures the maintenance of the proposed surgical technique, in such a situation. The dissection and transection of the duodenum was done 7 cm distally to the pylorus, under endoscopic view, proximally to the papillae, where the tissue was normal. Additionally, due the importance of the duodenal mucosa on minerals and trace elements absorption and the release of important hormones in this region, this case report elicits the evaluation of the impact of this technical modification, which occurred casually, in the nutritional, hormonal and metabolic results, long term. In this case report, the extended duodenal length has demonstrated reasonable weight loss, adequate comorbidities control and good nutritional status, so far. These aspects must be evaluated in the long term, by clinical trials.

Sleeve Gastrectomy Associated with Antral Lesion Resection and Roux-en-Y Antrojejunal Reconstruction

Obesity has been growing worldwide, reaching epidemic proportions. Bariatric surgery is the most effective and durable treatment for severe obesity and related diseases. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) are the most frequently performed bariatric operations, with long-term good results, in terms of weight loss and comorbidities control. Gastroesophageal Reflux Disease (GERD) is commonly associated with obesity. In general, it precludes the indication of sleeve gastrectomy, since this technique has a refluxogenic potential, as shown in many studies. In such cases, RYGB is considered the best surgery, reaching good weight loss and gastroesophageal reflux disease control. The drawback of this technique is that it leaves the remnant stomach, the duodenum, and the proximal part of the jejunum inaccessible. Besides, RYGB makes transoral endoscopic access to the biliary tree impossible. For all these reasons, this bariatric technique is not indicated in cases of gastric polyposis, gastric dysplasia, or strong family history of cancer, among others. We report a case of a morbidly obese patient with intense GERD, for whom a RYGB was precluded due to her strong family history of cancer, even knowing that it would be the best choice for reflux disease control. Instead, SG was chosen, even knowing it could worsen the gastroesophageal reflux disease. The patient signed an informed consent, after being fully enlightened about the risks. During the surgery, a small subserosal whitish lesion was detected, near the pylorus, on the anterior wall of the antrum. Thinking in a Gastrointestinal Stromal Tumor (GIST), it was resected, with a 2 cm safety margin, leaving a 4 to 5 cm hole on the gastric wall. The decision to maintain the proposed sleeve gastrectomy was made, to avoid leaving a remnant stomach, in a patient with such a strong family history of cancer. In the area of the resected lesion, an intraoperative decision was made not to just close the big gastric hole, being afraid of causing some anatomic or functional disturbance in gastric emptying. Instead, we decided to use the gastric opening to construct a Roux-en-Y antrotrojejunal anastomosis, with a 50 cm alimentary limb and a 200 cm biliopancreatic limb. Accordingly, it was performed a sleeve gastrectomy, associated with an antrojejunostomy in a Roux-en-Y fashion. The patient had an uneventful postoperative course. In the second year, she achieved normal weight and good nutritional status, without gastroesophageal reflux symptoms complaints. Seriography study shows that most of the contrast material passes through the antrojejunal anastomosis, instead of the pylorus, while the duodenum is endoscopically patent. This case report shows an unexpected surgical finding that led to a tactic of adding a Roux-en-Y gastric bypass in the antrum, associated with a sleeve gastrectomy, a strategy that may be adopted in cases of morbidly obese patients with important GERD, for whom gastrointestinal exclusions are contraindicated. To confirm this hypothesis, controlled studies are needed.

Hybrid Duodenal Transit Bipartition: An Endoscopic and Laparoscopic Metabolic Procedure

Obesity has been increasing significantly in Brazil and worldwide, becoming a major public health issue. Traditional prevention and treatment strategies, including behavioral interventions, nutritional modifications, physical activity, pharmacotherapy, and metabolic/bariatric procedures, have proven insufficient to reverse this trend. Bariatric surgery is recognized as the most effective treatment for obesity and its comorbidities, but it carries potential long-term risks. Hybrid Duodenal Transit Bipartition is proposed as a minimally invasive “endobariatric” procedure combining endoscopic sleeve gastroplasty (ESG) with laparoscopic duodenoileal or distal duodenojejunal anastomosis. The main objective of this study is to demonstrate the importance of the intestinal metabolic component of hybrid duodenal transit bipartition. This intestinal component is responsible for optimizing and attempting to maintain weight loss and control comorbidities from an ESG through the incretin stimulus generated by the early arrival of food in the ileum or distal jejunum (duodenoileal or distal duodenojejunal anastomosis). Additionally, it is a minimally invasive procedure that preserves the entire digestive system and does not involve gastrointestinal exclusion, allowing for endoscopic and nutritional access. To date, only one patient has undergone the hybrid duodenal bipartition procedure, with satisfactory early postoperative results at 60 days and weight loss exceeding the scientific literature on patients who underwent isolated endoscopic sleeve gastroplasty. Further studies are needed to validate these results and assess the long-term metabolic benefits of this new approach.