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

Victor Ramos Mussa Dib¹, Carlos Augusto Scussel Madalosso², Paulo Reis Esselin de Melo^3,4, Rui Ribeiro⁵, Paula Volpe⁶, Carlos Eduardo Domene⁶

¹Victor Dib Institute, Manaus, Brazil.
²Gastrobese Clinic, Passo Fundo, Brazil.
³Paulo Reis Institute of Bariatric Surgery, Goiânia, Brazil.
⁴Alfredo Nasser University Center (UNIFAN), Goiânia, Brazil.
⁵Lusíadas Amadora Hospital, Lisboa, Portugal.
⁶Integrated Center for Advanced Medicine (CIMAMED), São Paulo, Brazil.

DOI: 10.4236/ss.2024.153015                

Abstract

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.

Keywords

Roux-en-Y Gastric Bypass, Sleeve Gastrectomy, Jejuno Gastric Bypass, Vagus Nerve, Vagotomy, Bariatric Surgery

1. Introduction

Obesity has been growing worldwide and bariatric surgery is the most effective and durable treatment for patients with this disease [1] . There are a variety of surgeries, with it is proper mechanisms of action [2] [3] . Sleeve Gastrectomy (SG) and Roux-en-Y Gastric Bypass (RYGB) are the most frequently adopted operations [4] [5] .

SG can increase gastroesophageal reflux disease (GERD) incidence [6] [7] [8] , but carries the advantage of keeping intact the entire intestinal tract, diminishing nutritional problems and preserving peroral endoscopic and radiological access to it [9] . It has good metabolic effects and weight loss results in the mid-term, but concerning weight regain (WR), in the long-term [10] . There are some options of revisional surgeries after a failed sleeve gastrectomy [11] . Re-sleeve gastrectomy maybe applied, mainly if there is pronounced gastric tube dilation, with no severe GERD [12] [13] . If GERD is an important issue, this option is not advisable, since some authors have demonstrated high indices of GERD after revising a failed SG to Re-SG [14] [15] [16] . On the other hand, conversion to RYGB seems to bring similar results, compared to re-sleeve, in terms of weight loss, adding protection mechanisms against GERD [11] . One drawback of converting to RYGB is the diversion of the remnant stomach, the duodenum and the proximal jejunum that it promotes, which can cause some nutritional deficiencies and hinder peroral gastroduodenal endoscopic evaluation [17] - [22] . Recently we published a paper showing the association of SG with antrojejunal anastomosis, keeping the pylorus intact, in an obese patient with GERD. The with a 3-year follow-up showed good results in terms of weight loss and GERD control, surpassing the issues related to gastrointestinal diversions [23] . These principles could be applied as a revisional option, after a failed SG.

The current article reports two cases of obese patients who regained weight after SG and developed GERD (“De Novo GERD”). They had dilated sleeve tubes and were scheduled to a re-sleeve, associated with RYGB in the antrum [23] . The main intention in this proposal was to keep the rational that lead to the indication of primary SGs. In one case the Latarjet nerve was cut, due to a bleeding in the small gastric curvature and in the other, it was necessary to do a truncal vagotomy to facilitate hiatal hernia correction. The vagotomies led to pylorus spasm, which were identified in the postoperative endoscopic and radiologic evaluation. These findings rise a possibility of adding a selective vagotomy to a sleeve gastrectomy, with the intention to “close” the pylorus, associated with “Roux-en-Y” antrojejunal anastomosis, as a drainage procedure, mimicking a RYGB. This arrangement would avoid exclusions and allow duodenal access and could be applied in revisional or primary bariatric surgeries. To confirm this hypothesis, further investigation is necessary.

2. Patient Consent

The patients signed a Free and Informed Consent Form (FICF) and were informed about the procedure they would be undergoing, which would be a Re-sleeve Gastrectomy with a Roux-en-Y antrojejunal anastomosis. All their queries about the procedures were answered, in the presence of a companion. It was explained about possible intra and postoperative complications, as well as the possibility of changes in surgical planning, in case of intraoperative unexpected findings or intercurrences. An informed consent was signed by the patients, giving permission to use these cases details and images of the surgeries by the surgeon, for scientific purposes, preserving their identities. All the human data was performed, in accordance with the Declaration of Helsinki.

3. Cases Presentation

In this case report, two patients with previous SG had total weight regain and developed GERD (“De Novo GERD”), confirmed by validated questionnaire, upper endoscopy, upper gastrointestinal contrast study, HRM and I-pHmetry. In the primary operation, the choice for SG was done based on family history of gastric cancer (case one) and personal preferences (case two). Gastric tube dilation (more than 300 ml) was diagnosed in both cases by upper gastrointestinal contrast series and endoscopic evaluation, in both patients. The proposed surgical revision for them was a re-sleeve gastrectomy, associated with a gastric tube “drainage” procedure (Roux-en-Y antrojejunostomy). The aim of the gastroenterostomy was to reduce intragastric pressure, possibly helping in GERD control.

4. Case One

In the first case, the time span between the primary operation and the revision procedure was 6 years. In this case, the first operation was made by laparotomy. During the revisional surgery, due to dense adhesions between left hepatic lobe and stomach, a bleeding occurred on the level of the left gastric vessels, which required in-block hemostasis by electrical and ultrasonic coagulation. A complete cross sectioning of vessels and gastro-hepatic ligament were done at the mid small gastric curvature. The already scheduled antrojejunostomy gave us the confidence not to worry about Latarjet’s nerves cutting. The surgery was completed by laparoscopy without other intercurrences. No transfusion was required. The postoperative evolution was uneventful and the patient was discharged from hospital on the day after the surgery.

In Table 1, the overall characteristics of the first clinical case are presented.

5. Patient Overall Characteristics, Preoperative Evaluation and Surgical Technical Description in Case One

1) Patient demographics and preoperatory evaluation are described in Table 1.

1) Trocars, patient and surgical team position—these are described in Table 2 and shown in Figures 2-4.

2) Surgical steps on the first case are described in Table 3.

Table 1. First patient characteristics.

Figure 1. Dilated sleeve—radiological image.

Table 2. Surgical team, patient and trocars positions.

Figure 2. Trocars position.

Figure 3. Patient position.

Table 3. Surgical steps in case one.

Figure 4. Team position.

Figure 5. Abdominal cavity adhesions.

Figure 6. Left gastric vessels bleeding.

Figure 7. Dilated sleeve—laparoscopic view.

Figure 8. Resizing gastric tube.

Figure 9. Manual antrojejunal anastomosis.

Figure 10. Manual jejunum-jejunal anastomosis.

Figure 11. Schematic aspect of the surgery with Latarjet nerves septation.

6. Postoperative Evolution in Case One

One year follow-up:

● Weight—64 kg

● Weight loss—44 Kg

● BMI—25.3 Kg/m²

● %TWL—40.74%

● No antihypertensive medications, since the second postoperative month

● Snoring resolution

● Free of GERD symptoms (Validated Questionnaire)

● Hepatic steatosis resolution (Ultrassound)

● Good nutritional status

● Endoscopy—no hiatal hernia/no esophagitis/narrow sleeve tube/good aspect of 3 cm wide antrojejunal anastomosis, 1 cm proximal to the pylorus/spastic pylorus (Figure 12);

● Upper gastrointestinal contrast series—no hiatal hernia/no gastroesophageal reflux/narrow sleeve tube/contrast flows only to the jejunum (Figure 13).

7. Case Two

In this case, the time elapsed between the two operations was 8 years. The patient

Figure 12. Endoscopic aspect (spastic pylorus).

Figure 13. Postop radiological aspect (all the contrast to the jejunum).

had a pathological dilated gastric tube associated with a moderate hiatal hernia, seeing by upper radiologic gastrointestinal series and upper endoscopy. A strong inflammatory tissue in the hernia region and a stuck esophagus was found, during hiatal hernia repair, which hindered the dissection. A truncal vagotomy was done, to facilitate esophageal traction to the abdomen, without tension. The scheduled antrojejunostomy gave us the confidence to do the vagotomy, since a gastric drainage procedure was guaranteed.

In Table 4, the overall characteristics and preoperative evaluation of the second clinical case are presented.

Table 4. Second patient characteristics.

Figure 14. Dilated sleeve with hiatal hernia—radiological image.

8. Surgical Technical Description in Case Two

1) Trocars, patient and surgical team position—this is described in Table 2 and shown in Figures 2-4.

2) Surgical steps on the second case are described in Table 5.

Table 5. Surgical steps on the second case.

Figure 15. Adhesions between left hepatic lobe and stomach.

Figure 16. Enlarged hiatus.

Figure 17. Re-sleeved stomach, cruroplasty and Hiatal hernia repair.

Figure 18. Schematic aspect of the surgery with trucal vagotomy.

9. Postoperative Evolution in Case Two

One year follow-up case two:

● Weight—57 kg;

● Weight loss—46 Kg;

● BMI—24.6 Kg/m²;

● %TWL—44.66%;

● No antihypertensive medications, since the fourth postoperative month;

● No antidiabetic medications since the surgery;

● Sleep apnea resolution;

● Free of GERD symptoms (Validated Questionnaire);

● Hepatic steatosis resolution (Ultrassound);

● Normalization of cholesterol, triglycerides;

● Good nutritional status;

● Endoscopy—no hiatal hernia/no esophagitis/narrow sleeve tube, good aspect of 4 cm wide antrojejunal anastomosis, 1 cm proximal to the pylorus (Figure 19);

● Seriography—no hiatal hernia/no gastroesophageal reflux/no sleeve dilation/contrast only flows to the jejunum (Figure 20).

Figure 19. Postop endoscopy—spastic pylorus.

Figure 20. Postoperative radiological aspect—all the contrast flowing to the Roux limb.

10. Discussion

Sleeve gastrectomy is the most common bariatric surgery performed, worldwide [4] . Nonetheless, it has considerable indices of failure in the long term, that can reach 30% to 50% [11] [24] . Besides, many studies have demonstrated that SG has a potential for gastroesophageal reflux development, which can worsen a pre-existing GERD or lead to its new onset (“De Novo GERD”) [25] [26] [27] [28] [29] . In this case report, both patients were submitted to primary SL, regained weight and developed “De Novo GERD”. Increased intragastric pressure, loss of gastric complacency, disruption of crura structure, proximal gastric tube migration, fundus compression absence and gastric tube tortuosity are some of the factors involved in the pathophysiology of gastroesophageal reflux, after this operation [6] [30] [31] [32] , which can limit its indication.

There are many possible causes related to WR after SG, but a dilation of gastric tube (more than 225 ml) in the first 2 to 3 years after surgery is frequently associated with it [12] . Upper gastrointestinal radiological contrast series and computed tomography with 3D gastric volumetry reconstruction are very useful tools in this diagnosis [33] [34] [35] . The two patients of this study had gastric sleeve dilation, diagnosed by upper gastrointestinal contrast series.

Not infrequently, WR and GERD are associated, after SG [36] . Interestingly, some of these patients have no complaints related to GERD and esophageal motility alterations are not an uncommon find [37] [38] . Based on that, it is very important to do a thorough preoperative evaluation of gastroesophageal reflux disease and esophageal motility disorders, including symptoms evaluation (validated questionnaires), endoscopy, HRM and impedance pHmetry, mainly in patients with WR, in whom a revisional surgery is being planned. This preoperative protocol was utilized herein, confirming GERD presence.

The presence of weight regains and GERD after SG can limit the surgical revisional options. Some techniques are more “potent” than SG and would achieve better weight loss, but could perpetuate GERD or even, worsen it [39] . Combining a gastrointestinal anastomosis with a sleeved pouch can improve reflux symptoms, by decompressing the pouch [40] . Some authors demonstrated this decompression effect in rodents and its protective action against gastroesophageal reflux after sleeve gastrectomy [41] . In this current study, where both patients developed GERD associated with WR, we observed a significant GERD improvement after revisional surgery, by adding an antrojejunal anastomosis in the re-sleeved gastric tube, which was confirmed either by symptoms relief (validated questionnaire), endoscopic assess and functional esophageal studies. This improvement is probably attributed to the gastric tube decompression, promoted by this gastrointestinal anastomosis.

The best approach to deal with reflux disease after SG, according to literature, is converting it to RYGB, but it’s not the best alternative to address weight regain [42] [43] . Some of the reasons related to the improvement of GERD after converting SG to gastric bypass are the low acidity of a small gastric pouch, the expedited gastric emptying and the absence of bile, due to the Roux-en-Y configuration [44] [45] . Although gastric bypass can add little in terms of weight loss, after a failed SG, it can achieve better metabolic results, showing higher resolution or control rates of diabetes, hypertension, dyslipidemia and other metabolic issues [46] . These results, including weight loss, can be improved by lengthening the biliopancreatic limb (BPL) [47] [48] [49] [50] . The same metabolic improvement has been shown with One Anastomosis Gastric Bypass (OAGB), which has a long biliopancreatic limb, compared to standard RYGB [51] . Based on that, in the current study, as the patients had WR and worsening of metabolic conditions, we opted for a longer BPL length to achieve a better weight loss and metabolic control.

Some authors described no correlation between gastric pouch size and total weight loss, at one year after RYGB, but call attention to the increased incidence of marginal ulcers in larger pouches [52] . On the contrary, Rui Ribeiro et al. [53] , in a cohort of 300 patients, described a long tubular gastric pouch RYGB, with low incidence of marginal ulcers, which occurred in 1% of patients, in a 4-year follow-up. The low frequency of these ulcers could be attributed to the tubular and narrow gastric pouch, made over a 36Fr bougie, removing parietal cells. Still considering marginal ulcers, many studies have demonstrated the safety of antral-enteric anastomosis, with very low complication rates, which made us feel comfortable in doing it [54] [55] [56] . In this current case report, both patients had no marginal ulcers, which is in accordance with literature. Furthermore, it was already stablished a reduction in gastric acid production after vagotomies, due to inhibition of parasympathetic stimulus to parietal cells. This contributes to reducing gastroduodenal ulcers incidence as well as marginal ulcers in gastrointestinal anastomosis [57] [58] . In the revisional procedures studied herein, the addition of vagotomies, either truncal or selective, may have contributed for diminishing the already low incidence of marginal ulcers, seeing in SG associated with antrojejunal anastomosis.

A longer gastric pouch seems to protect against dumping syndrome and hyperinsulinemic hypoglycemia, due to a slower rate of gastric emptying, according to some authors [53] . In this current case report, both patients had no complaints of dumping syndrome or hypoglycemia, probably due to the reasons mentioned above.

One disadvantage of converting SG to RYGB for the treatment of WR or IWL, is the exclusion of gastric remnant, the duodenum and part of the jejunum. This precludes future peroral endoscopic evaluations of these segments and makes biliary tree and pancreatic ducts accessibility cumbersome [59] . These exclusions can make RYGB inappropriate for patients with previous gastroduodenal ulcers, gastric polyps, gastric dysplasia, strong family history of cancer, intractable H. pylori, among others [60] . Also, there are inferences of a cancer environment in the excluded gastric chamber [22] . Recently, we reported a case of a primary SG associated with Roux-en-Y antrojejunal anastomosis, in a morbidly obese patient with GERD. This approach controlled both diseases, in a 3-years follow-up, avoiding exclusions and keeping duodenum accessibility, which could solve the issues related to RYGB [23] . These same principles were replicated in the revisional cases of this study, with the addition of either selective or truncal vagotomies, for the reasons already mentioned.

Back in the 70s and 80s, lots of studies demonstrated the effect of a vagotomy (truncal or selective) on the pylorus, causing its long-lasting spasm, which required a concomitant gastric drainage (pyloroplasty, pyloromyotomy, antrectomy or gastrointestinal anastomosis), as part of the operation [61] [62] . Based on that, we assumed during the surgeries of this study that a pyloric spasm would happen, because of the vagal nerve transection. As an antrojejunal anastomosis was scheduled in both cases beforehand, it would work as a gastric drainage procedure, which would be necessary. During the postoperative endoscopy and upper radiologic contrast study series it was confirmed a spastic pylorus in both cases, during the one-year follow-up, which was attributed to the vagotomies, leading to a deviation of all the contrast flow to the Roux limb. Noteworthy was the pyloric patency to the endoscope, in both patients, requiring a little pushing pressure on it. Due to the gastrointestinal anastomosis, there was no gastric stasis in neither case as well as, no symptoms of fulness.

There are some undesirable effects of truncal vagotomy, that are less frequent in selective ones. Dumping syndrome and chronic diarrhea can be cumbersome in truncal vagotomies, although there is a trend to improvement with time [63] [64] [65] [66] . In the patients operated in this study there were no complications attributed to the vagotomies, including diarrhea or dumping syndrome.

The revisional configuration showed in this case report could represent a “Functional RYGB” (F-RYGB), with a long gastric pouch and no exclusions, preserving peroral endoscopic duodenal and biliopancreatic tract accessibility. Greco et al. demonstrated a functional OAGB as a revisional procedure for a failed SG. The authors used a non-adjustable ring over the level of angular incisura of the sleeve tube, adding the intestinal anastomosis just above the ring. The purposes were to avoid dissections and stapling in the antral area. This operation also keeps endoscopic accessibility to the duodenum, as there is enough space for the endoscope to pass through the ring area. It was observed in contrast studies a preferential flow to the gastrointestinal anastomosis, instead of the antrum [67] . In the cases of the current study, we accomplished a F-RYGB without foreign bodies, due to a probable neuromuscular mechanism triggered by the vagotomies, that lead to pyloric spasm. A complete contrast flow to the gastrointestinal anastomosis was demonstrated in upper radiological contrast studies. This possibly discards a bipartition of the gastrointestinal transit and brings a probable replication of the well-known results of the RYGB, largely demonstrated in literature [24] [68] . In the period of 1-year follow-up, the two patients discussed herein achieved total disappearance of reflux symptoms, healing of esophagitis and adequate weight loss, results compatible and comparable with the ones obtained with a Roux-en-Y gastric bypass, mainly if a longer BPL is employed, as it was in our study.

Some limitations of this study are related to the non-existence of a preoperative protocol in relation to vagotomy use, since the vagotomies weren’t scheduled, the small number of patients, the absence of control group and the shortness of the follow-up period.

11. Conclusion

This case report demonstrates a surgical revisional strategy for a failed SG, that makes possible to keep the primary operation rational, in patients with insufficient weight loss, obesity recidivism and/or gastroesophageal reflux disease. By re-sleeving a dilated gastric sleeve pouch (if dilated) and adding an antrojejunal anastomosis, as a gastric drainage procedure, this could be achieved. The association of a Latarjet’s nerve septation to this procedure can lead to a pyloric spasm, directing the ingested food entirely to the Roux limb, replicating the well-known results of RYGB. This operation could represent a functional RYGB (F-RYGB), without foreign bodies, which could be indicated as a primary bariatric surgery, either. This would bring the advantage of having no exclusions, with preservation of peroral endoscopic duodenal and biliopancreatic ducts access, while adding an anti-reflux mechanism to a gastric sleeved pouch, gathering the advantages of both techniques, SG and RYGB. Additional studies are needed to further evaluation of this hypothesis.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References

[1]	Blüher, M. (2019) Obesity: Global Epidemiology and Pathogenesis. Nature Reviews Endocrinology, 15, 288-298. https://doi.org/10.1038/s41574-019-0176-8
[2]	Guerreiro, V., Neves, J.S., Salazar, D., Ferreira, M.J., Oliveira, S.C., Souteiro, P., Pedro, J., Magalhães, D., Varela, A., Belo, S., Freitas, P., Carvalho, D., et al. (2019) Long-Term Weight Loss and Metabolic Syndrome Remission after Bariatric Surgery: The Effect of Sex, Age, Metabolic Parameters and Surgical Technique—A 4-Year Follow-Up Study. Obesity Facts, 12, 639-652. https://doi.org/10.1159/000503753
[3]	Aarts, E.O. and Mahawar, K. (2020) From the Knife to the Endoscope—A History of Bariatric Surgery. Current Obesity Reports, 9, 348-363. https://doi.org/10.1007/s13679-020-00382-1
[4]	Welbourn, R., Hollyman, M., Kinsman, R., et al. (2019) Bariatric Surgery Worldwide: Baseline Demographic Description and One-Year Outcomes from the Fourth IFSO Global Registry Report 2018. Obesity Surgery, 29, 782-795. https://doi.org/10.1007/s11695-018-3593-1
[5]	English, W.J., Demaria, E., Hutter, M., et al. (2020) American Society for Metabolic and Bariatric Surgery 2018 Estimate of Metabolic and Bariatric Procedures Performed in the United States. Surgery for Obesity and Related Diseases, 16, 457-463. https://doi.org/10.1016/j.soard.2019.12.022
[6]	Quero, G., Fiorillo, C., Dallemagne, B., et al. (2020) The Causes of Gastroesophageal Reflux after Laparoscopic Sleeve Gastrectomy: Quantitative Assessment of the Structure and Function of the Esophagogastric Junction by Magnetic Resonance Imaging and High-Resolution Manometry. Obesity Surgery, 30, 2108-2117. https://doi.org/10.1007/s11695-020-04438-y
[7]	Rebecchi, F., Allaix, M.E., Giaccone, C., Ugliono, E., Scozzari, G. and Morino, M. (2014) Gastroesophageal Reflux Disease and Laparoscopic Sleeve Gastrectomy: A Physiopathologic Evaluation. Annals of Surgery, 260, 909-914. https://doi.org/10.1097/SLA.0000000000000967
[8]	Braghetto, I., Csendes, A., Korn, O., Valladares, H., Gonzalez, P. and Henríquez, A. (2010) Gastroesophageal Reflux Disease after Sleeve Gastrectomy. Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 20, 148-153. https://doi.org/10.1097/SLE.0b013e3181e354bc
[9]	Kheirvari, M., Nikroo, N.D., Jaafarinejad, H., et al. (2020) The Advantages and Disadvantages of Sleeve Gastrectomy; Clinical Laboratory to Bedside Review. Heliyon, 6, e03496. https://doi.org/10.1016/j.heliyon.2020.e03496
[10]	Clapp, B., Wynn, M., Martyn, C., Foster, C., O’Dell, M. and Tyroch, A. (2018) Long term (7 or More Years) Outcomes of the Sleeve Gastrectomy: A Meta-Analysis. Surgery for Obesity and Related Diseases, 14, 741-747. https://doi.org/10.1016/j.soard.2018.02.027
[11]	Guan, B., Chong, T.H., Peng, J., Chen, Y., Wang, C. and Yang, J. (2019) Mid-Long-Term Revisional Surgery after Sleeve Gastrectomy: A Systematic Review and Meta-Analysis. Obesity Surgery, 29, 1965-1975. https://doi.org/10.1007/s11695-019-03842-3
[12]	Deguines, J.B., Verhaeghe, P., Yzet, T., Robert, B., Cosse, C. and Regimbeau, J.M. (2013) Is the Residual Gastric Volume after Laparoscopic Sleeve Gastrectomy an Objective Criterion for Adapting the Treatment Strategy after Failure? Surgery for Obesity and Related Diseases, 9, 660-666. https://doi.org/10.1016/j.soard.2012.11.010
[13]	Cesana, G., Uccelli, M., Ciccarese, F., Carrieri, D., Castello, G. and Olmi, S. (2014) Laparoscopic Re-Sleeve Gastrectomy as a Treatment of Weight Regain after Sleeve Gastrectomy. World Journal of Gastrointestinal Surgery, 6, 101-106. https://doi.org/10.4240/wjgs.v6.i6.101
[14]	Lacy, A., Ibarzabal, A., Pando, E., Adelsdorfer, C., Delitala, A., Corcelles, R., Delgado, S. and Vidal, J. (2010) Revisional Surgery after Sleeve Gastrectomy. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 20, 351-356. https://doi.org/10.1097/SLE.0b013e3181f62895
[15]	Nedelcu, M., Noel, P., Iannelli, A. and Gagner, M. (2015) Revised Sleeve Gastrectomy (Re-Sleeve). Surgery for Obesity and Related Diseases, 11, 1282-1288. https://doi.org/10.1016/j.soard.2015.02.009
[16]	Angelis, D.F., Avallone, M., Albanese, A., Foletto, M. and Silecchia, G. (2018) Re-Sleeve Gastrectomy 4 Years Later: Is It Still an Effective Revisional Option? Obesity Surgery, 28, 3714-3716. https://doi.org/10.1007/s11695-018-3481-8
[17]	Gu, L., Fu, R., Chen, P., et al. (2020) In Terms of Nutrition, the Most Suitable Method for Bariatric Surgery: Laparoscopic Sleeve Gastrectomy or Roux-en-Y Gastric Bypass? A Systematic Review and Meta-Analysis. Obesity Surgery, 30, 2003-2014. https://doi.org/10.1007/s11695-020-04488-2
[18]	Hassan zadeh, M., Farsani, M.G. and Zamaninour, N. (2019) Selenium Status after Roux-en-Y Gastric Bypass: Interventions and Recommendations. Obesity Surgery, 29, 3743-3748. https://doi.org/10.1007/s11695-019-04148-0
[19]	Cheng, Q., Hort, A., Yoon, P., et al. (2021) Review of the Endoscopic, Surgical and Radiological Techniques of Treating Choledocholithiasis in Bariatric Roux-en-Y Gastric Bypass Patients and Proposed Management Algorithm. Obesity Surgery, 31, 4993-5004. https://doi.org/10.1007/s11695-021-05627-z
[20]	Kumar, P., Yau, H.-C.V., Trivedi, A., et al. (2020) Global Variations in Practices Concerning Roux-en-Y Gastric Bypass—An Online Survey of 651 Bariatric and Metabolic Surgeons with Cumulative Experience of 158,335 Procedures. Obesity Surgery, 30, 4339-4351. https://doi.org/10.1007/s11695-020-04796-7
[21]	Chemaly, R., Diab, S., Khazen, G., et al. (2022) Gastroesophageal Cancer after Gastric Bypass Surgeries: A Systematic Review and Meta-Analysis. Obesity Surgery, 32, 1300-1311. https://doi.org/10.1007/s11695-022-05921-4
[22]	Ravacci, G.R., Ishida, R., Torrinhas, R.S., et al. (2019) Potential Premalignant Status of Gastric Portion Excluded after Roux en-Y Gastric Bypass in Obese Women: A Pilot Study. Scientific Reports, 9, Article No. 5582. https://doi.org/10.1038/s41598-019-42082-4
[23]	Dib, V.R.M., Madalosso, C.A.S., Domene, C.E., de Melo, P.R.E., Ribeiro, R., Scortegagna, G.T. and Chaim, E.A. (2023) Sleeve Gastrectomy Associated with Antral Lesion Resection and Roux-en-Y Antrojejunal Reconstruction. Surgical Science, 14, 360-376. https://doi.org/10.4236/ss.2023.145041
[24]	Sharples, A.J. and Mahawar, K. (2020) Systematic Review and Meta-Analysis of Randomised Controlled Trials Comparing Long-Term Outcomes of Roux-En-Y Gastric Bypass and Sleeve Gastrectomy. Obesity Surgery, 30, 664-672. https://doi.org/10.1007/s11695-019-04235-2
[25]	Oraby, E.M., Harb, O.A. and Bahbah, M.A. (2022) Concomitant Obesity and GERD: Is Laparoscopic Sleeve Gastrectomy Still Considered the Best Option? A Clinical and Endoscopic Evaluation. World Journal of Laparoscopic Surgery, 15, 266-271.
[26]	Elkassem, S. (2021) Gastroesophageal Reflux Disease, Esophagitis, and Barrett’s Esophagus 3 to 4 Years Post Sleeve Gastrectomy. Obesity Surgery, 31, 5148-5155. https://doi.org/10.1007/s11695-021-05688-0
[27]	Kermansaravi, M., Amr, B., Kabir, A., et al. (2023) Endoscopic Evaluation of de Novo Esophagitis and Barrett’s Esophagus, 5 Years after Sleeve Gastrectomy. Obesity Surgery, 33, 256-262. https://doi.org/10.1007/s11695-022-06403-3
[28]	Raj, P.P., Bhattacharya, S., Misra, S., Kumar, S.S., Khan, M.J., Gunasekaran, S.C. and Palanivelu, C. (2019) Gastroesophageal Reflux-Related Physiologic Changes after Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: A Prospective Comparative Study. Surgery for Obesity and Related Diseases, 15, 1261-1269. https://doi.org/10.1016/j.soard.2019.05.017
[29]	Navarini, D., Madalosso, C.A.S., Tognon, A.P., et al. (2020) Predictive Factors of Gastroesophageal Reflux Disease in Bariatric Surgery: A Controlled Trial Comparing Sleeve Gastrectomy with Gastric Bypass. Obesity Surgery, 30, 1360-1367. https://doi.org/10.1007/s11695-019-04286-5
[30]	da Silva, J.-T.D., Santa-Cruz, F., Cavalcanti, J.M.S., et al. (2023) Incidence of Abnormalities of the Gastric Tube Following Sleeve Gastrectomy and Its Role on Esophagitis Progression. Obesity Surgery, 33, 263-267. https://doi.org/10.1007/s11695-022-06375-4
[31]	Alvarez, R., Youssef, J., Zadeh, J., et al. (2023) Sleeve Gastrectomy Morphology and Long-Term Weight-Loss and Gastroesophageal Reflux Disease Outcomes. Surgical Endoscopy, 37, 5652-5664. https://doi.org/10.1007/s00464-022-09555-6
[32]	Chern, T.Y., Chan, D.L., Maani, J., Ferguson, J.S. and Talbot, M.L. (2021) High-Resolution Impedance Manometry and 24-hour Multichannel Intraluminal Impedance with pH Testing before and after Sleeve Gastrectomy: De Novo Reflux in a Prospective Series. Surgery for Obesity and Related Diseases, 17, 329-337. https://doi.org/10.1016/j.soard.2020.09.030
[33]	Keidar, A., Appelbaum, L., Schweiger, C., Elazary, R. and Baltasar, A. (2010) Dilated Upper Sleeve Can be Associated with Severe Postoperative Gastroesophageal Dysmotility and Reflux. Obesity Surgery, 20, 140-147. https://doi.org/10.1007/s11695-009-0032-3
[34]	Stier, C., Parmar, C., Koschker, A.C., Bokhari, M., Stier, R. and Chiappetta, S. (2020) Computed Tomography-3D-Volumetry: A Valuable Adjunctive Diagnostic Tool after Bariatric Surgery. Mini-Invasive Surgery, 4, Article 18. https://doi.org/10.20517/2574-1225.2019.75
[35]	Baumann, T., Grueneberger, J., Pache, G., et al. (2011) Three-Dimensional Stomach Analysis with Computed Tomography after Laparoscopic Sleeve Gastrectomy: Sleeve Dilation and Thoracic Migration. Surgical Endoscopy, 25, 2323-2329. https://doi.org/10.1007/s00464-010-1558-0
[36]	Felsenreich, D.M., Langer, F.B., Kefurt, R., Panhofer, P., Schermann, M., Beckerhinn, P., Sperker, C. and Prager, G. (2016) Weight Loss, Weight Regain, and Conversions to Roux-en-Y Gastric Bypass: 10-Year Results of Laparoscopic Sleeve Gastrectomy. Surgery for Obesity and Related Diseases, 12, 1655-1662. https://doi.org/10.1016/j.soard.2016.02.021
[37]	Suter, M., Dorta, G., Giusti, V. and Calmes, J.M. (2004) Gastro-Esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients. Obesity Surgery, 14, 959-966. https://doi.org/10.1381/0960892041719581
[38]	Brunaldi, V.O., Abboud, D.M., Abusaleh, R.R., Annan, K.A., Razzak, F.A., Ravi, K., Valls, E.J.V., Storm, A.C., Ghanem, O.M. and Abu Dayyeh, B.K. (2024) Post-Bariatric Surgery Changes in Secondary Esophageal Motility and Distensibility Parameters. Obesity Surgery, 34, 347-354. https://doi.org/10.1007/s11695-023-06959-8
[39]	Sudan, R. and Jain-Spangler, K. (2018) Tailoring Bariatric Surgery: Sleeve Gastrectomy, Roux-en-Y Gastric Bypass and Biliopancreatic Diversion with Duodenal Switch. Journal of Laparoendoscopic & Advanced Surgical Techniques and Videoscopy, 28, 956-961 https://doi.org/10.1089/lap.2018.0397
[40]	Aghajani, E., Schou, C., Gislason, H. and Nergaard, B.J. (2023) Mid-Term Outcomes after Single Anastomosis Sleeve Ileal (SASI) Bypass in Treatment of Morbid Obesity. Surgical Endoscopy, 37, 6220-6227. https://doi.org/10.1007/s00464-023-10112-y
[41]	Wang, M., Widjaja, J., Dolo, P.R., Yao, L., Hong, J. and Zhu, X. (2022) The Protective Effect of Transit Bipartition and Its Modification Against Sleeve Gastrectomy-Related Esophagitis in a Rodent Model. Obesity Surgery, 32, 1149-1156. https://doi.org/10.1007/s11695-022-05907-2
[42]	Parmar, C.D., Mahawar, K.K., Boyle, M., Schroeder, N., Balupuri, S. and Small, P.K. (2017) Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass is Effective for Gastro-Oesophageal Reflux Disease but not for Further Weight Loss. Obesity Surgery, 27, 1651-1658. https://doi.org/10.1007/s11695-017-2542-8
[43]	Frankel, A., Thomson, I., Shah, A., Chen, C., Zahir, S.F., Barbour, A., Holtmann, G. and Smithers, B.M. (2022) Laparoscopic Fundoplication versus Laparoscopic Roux-en-Y Gastric Bypass for Gastro-Oesophageal Reflux Disease in Obese Patients: Protocol for a Randomized Clinical Trial. BJS Open, 6, zrac132. https://doi.org/10.1093/bjsopen/zrac132
[44]	Mejía-Rivas, M.A., Herrera-López, A., Hernández-Calleros, J., et al. (2008) Gastroesophageal Reflux Disease in Morbid Obesity: The Effect of Roux-en-Y Gastric Bypass. Obesity Surgery, 18, 1217-1224. https://doi.org/10.1007/s11695-008-9474-2
[45]	Gu, L., Chen, B., Du, N., et al. (2019) Relationship Between Bariatric Surgery and Gastroesophageal Reflux Disease: A Systematic Review and Meta-Analysis. Obesity Surgery, 29, 4105-4113. https://doi.org/10.1007/s11695-019-04218-3
[46]	Zhou, K., Wolski, K., Malin, S.K., Aminian, A., Schauer, P.R., Bhatt, D.L. and Kashyap, S.R. (2019) Impact of Weight Loss Trajectory Following Randomization to Bariatric Surgery on Long-Term Diabetes Glycemic and Cardiometabolic Parameters. Endocrine Practice, 25, 572-579. https://doi.org/10.4158/EP-2018-0522
[47]	Zorrilla-Nunez, L.F., Campbell, A., Giambartolomei, G., Lo Menzo, E., Szomstein, S. and Rosenthal, R.J. (2019) The Importance of the Biliopancreatic Limb Length in Gastric bypass: A Systematic Review. Surgery for Obesity and Related Diseases, 15, 43-49. https://doi.org/10.1016/j.soard.2018.10.013
[48]	Kamocka, A., Chidambaram, S., Erridge, S., et al. (2022) Length of Biliopancreatic Limb in Roux-en-Y Gastric Bypass and its Impact on Post-Operative Outcomes in Metabolic and Obesity Surgery—Systematic Review and Meta-Analysis. International Journal of Obesity, 46, 1983-1991. https://doi.org/10.1038/s41366-022-01186-0
[49]	Kwon, Y., Lee, S., Kim, D., ALRomi, A., Park, S.-H., Lee, C.M., Kim, J.H. and Park, S. (2022) Biliopancreatic Limb Length as a Potential Key Factor in Superior Glycemic Outcomes after Roux-en-Y Gastric Bypass in Patients with Type 2 Diabetes: A Meta-Analysis. Diabetes Care, 45, 3091-3100. https://doi.org/10.2337/dc22-0835
[50]	Murad Jr., A.J., Cohen, R.V., de Godoy, E.P., Scheibe, C.L., Campelo, G.P., Ramos, A.C., de Lima, R.C., Pinto, L.E.V., Coelho, D., Costa, H.B.F., Pinto, í.M.P., Pereira, T., Teófilo, F.R.S. and Valadão, J.A. (2018) A Prospective Single-Arm Trial of Modified Long Biliopancreatic and Short Alimentary Limbs Roux-En-Y Gastric Bypass in Type 2 Diabetes Patients with Mild Obesity. Obesity Surgery, 28, 599-605. https://doi.org/10.1007/s11695-017-2933-x
[51]	Wilczyński, M., Spychalski, P., Proczko-Stepaniak, M., Bigda, J., Szymański, M., Dobrzycka, M., Rostkowska, O. and Kaska, Ł. (2022) Comparison of the Long-Term Outcomes of RYGB and OAGB as Conversion Procedures after Failed LSG—A Case-Control Study. Journal of Gastrointestinal Surgery, 26, 2255-2265. https://doi.org/10.1007/s11605-022-05395-w
[52]	Edholm, D., Ottosson, J. and Sundbom, M. (2016) Importance of Pouch Size in Laparoscopic Roux-en-Y Gastric Bypass: A Cohort Study of 14,168 Patients. Surgical Endoscopy, 30, 2011-2015. https://doi.org/10.1007/s00464-015-4432-2
[53]	Ribeiro, R., Pouwels, S., Parmar, C., Pereira, J., Manaças, L., Guerra, A., Borges, N., Ribeiro, J. and Viveiros, O. (2019) Outcomes of Long Pouch Gastric Bypass (LPGB): 4-Year Experience in Primary and Revision Cases. Obesity Surgery, 29, 3665-3671. https://doi.org/10.1007/s11695-019-04051-8
[54]	Santoro, S., Castro, L.C., Velhote, M.C., Malzoni, C.E., Klajner, S., Castro, L.P., Lacombe, A. and Santo, M.A. (2012) Sleeve Gastrectomy with Transit Bipartition: A Potent Intervention for Metabolic Syndrome and Obesity. Annals of Surgery, 256, 104-110. https://doi.org/10.1097/SLA.0b013e31825370c0
[55]	Pazouki, A. and Kermansaravi, M. (2019) Single Anastomosis Sleeve-Jejunal Bypass: A New Method of Bariatric/Metabolic Surgery. Obesity Surgery, 29, 3769-3770. https://doi.org/10.1007/s11695-019-04016-x
[56]	Sewefy, A.M. and Saleh, A. (2021) The Outcomes of Single Anastomosis Sleeve Jejunal Bypass as a Treatment for Morbid Obesity (Two-Year Follow-Up). Surgical Endoscopy, 35, 5698-5704. https://doi.org/10.1007/s00464-020-08029-x
[57]	Thompson, J.C., Lowder, W.S., Peurifoy, J.T., Swierczek, J.S. and Rayford, P.L. (1978) Effect of Selective Proximal Vagotomy and Truncal Vagotomy on Gastric Acid and Serum Gastrin Responses to a Meal in Duodenal Ulcer Patients. Annals of Surgery, 188, 431-438. https://doi.org/10.1097/00000658-197810000-00001
[58]	Poon, R., Chow, L., Lim, B. and Gertsch, P. (1997) Thoracoscopic Vagotomy For Recurrent Ulcer after Previous Gastric Operation. Australian and New Zealand Journal of Surgery, 67, 177-180. https://doi.org/10.1111/j.1445-2197.1997.tb01935.x
[59]	Connell, M., Sun, W.Y.L., Mocanu, V., et al. (2022) Management of Choledocholithiasis after Roux-en-Y Gastric Bypass: A Systematic Review and Pooled Proportion Meta-Analysis. Surgical Endoscopy, 36, 6868-6877. https://doi.org/10.1007/s00464-022-09018-y
[60]	Alimadadi, M., Seyedmajidi, S., Safamanesh, S., Zanganeh, E., Hosseini, S.A., Hajiebrahimi, S. and Seyyedmajidi, M. (2022) Preoperative Esophagogastroduodenoscopy Findings and Effects on Laparoscopic Roux-en-Y Gastric Bypass in Area with High Prevalence of Helicobacter Pylori Infection: Multi-Center Experience in Iran. Gastroenterology and Hepatology from Bed to Bench, 15, 53-58.
[61]	Goligher, J.C., Pulvertaft, C.N., Irvin, T.T., Johnston, D., Walker, B., Hall, R.A., et al. (1972) Five- to Eight-Year Results of Truncal Vagotomy and Pyloroplasty for Duodenal Ulcer. The British Medical Journal, 1, 7-13. https://doi.org/10.1136/bmj.1.5791.7
[62]	Kronborg, O. and Madsen, P. (1975) A Controlled, Randomized Trial of Highly Selective Vagotomy versus Selective Vagotomy and Pyloroplasty in the Treatment of Duodenal Ulcer. Gut, 16, 268-271. https://doi.org/10.1136/gut.16.4.268
[63]	Russell, R.C., Thomson, J.P. and Bloom, S.R. (1974) The Effect of Truncal and Selective Vagotomy on the Release of Pancreatic Glucagon, Insulin and Enteroglucagon. British Journal of Surgery, 61, 821-824. https://doi.org/10.1002/bjs.1800611017
[64]	Kennedy, T., Connell, A.M., Love, A.H., MacRae, K.D. and Spencer, E.F. (1973) Selective or Truncal Vagotomy? Five-Year Results of a Double-Blind, Randomized, Controlled Trial. British Journal of Surgery, 60, 944-948. https://doi.org/10.1002/bjs.1800601208
[65]	Craft, I.L. and Venables, C.W. (1968) Antiperistaltic Segment of Jejunum for Persistent Diarrhea Following Vagotomy. Annals of Surgery, 167, 282-286. https://doi.org/10.1097/00000658-196802000-00020
[66]	Herrington Jr., J.L., Edwards, W.H., Carter, J.H. and Sawyers, J.L. (1968) Treatment of Severe Postvagotomy Diarrhea by Reversed Jejunal Segment. Annals of Surgery, 168, 522-541. https://doi.org/10.1097/00000658-196809000-00017
[67]	Greco, F. (2017) Conversion of Vertical Sleeve Gastrectomy to a Functional Single-Anastomosis Gastric Bypass: Technique and Preliminary Results Using a Non-Adjustable Ring Instead of Stapled Division. Obesity Surgery, 27, 896-901. https://doi.org/10.1007/s11695-016-2392-9
[68]	Obeid, N.R., Malick, W., Concors, S.J., Fielding, G.A., Kurian, M.S. and Ren-Fielding, C.J. (2016) Long-Term Outcomes after Roux-en-Y Gastric Bypass: 10- to 13-Year Data. Surgery for Obesity and Related Diseases, 12, 11-20. https://doi.org/10.1016/j.soard.2015.04.011