Patrick Noel

Background: Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SG) (SADI-S) and distal one anastomosis transit bipartition (dOATB) represent two distal single-anastomosis metabolic procedures sharing similar anatomical configurations but differing fundamentally in their approach to duodenal transit. Both combine SG with an omega-loop anastomosis to the distal ileum approximately 250–300 cm from the ileocecal valve. However, SADI-S positions the anastomosis on the duodenal bulb, achieving complete duodenal exclusion, while dOATB performs a prepyloric antral anastomosis, preserving duodenal transit through a bipartition mechanism. This fundamental difference raises a critical question: Does complete duodenal exclusion matter for metabolic outcomes in distal intestinal procedures? Methods: We conducted a narrative review comparing anatomical, physiological, and clinical aspects of SADI-S and dOATB, emphasizing the role of duodenal exclusion in weight loss (WL), metabolic improvements, and nutritional consequences. We examined the hypotheses to provide a theoretical framework for understanding these procedures. Results: Both procedures demonstrate excellent WL, with total WL ranging from 35% to 45% and excess WL exceeding 80% at medium-term follow-up. Type 2 diabetes remission rates are remarkably high in both groups (85%–95%). SADI-S has a more extensive evidence base with longer follow-up and IFSO and ASMBS endorsement. Distal OATB, while demonstrating comparable metabolic efficacy, offers theoretical advantages in nutritional preservation through maintained duodenal transit and facilitated endoscopic access to the biliopancreatic system. The holoileum hypothesis suggests that adequate ileal stimulation through an elongated common channel may be more important than duodenal exclusion per se . Conclusions: Current evidence suggests that excellent metabolic outcomes can be achieved with distal single-anastomosis procedures regardless of duodenal exclusion status. The elongated common channel and ileal stimulation appear to be the critical determinants of metabolic success. Distal OATB may offer advantages in nutritional preservation and endoscopic accessibility while maintaining comparable metabolic efficacy. Prospective randomized trials directly comparing these procedures are warranted.

Background: Marginal ulcer (MU) is a well-recognized complication following Roux-en-Y gastric bypass (RYGB), with a reported prevalence of 0.6%–16%. While most ulcers respond to medical therapy with proton pump inhibitors and risk factor modification, a subset of patients develop refractory ulcers requiring surgical intervention. Despite this clinical challenge, there remains no consensus on the optimal surgical approach for refractory MU. Methods: We performed a narrative review of the literature using PubMed, MEDLINE, and Google Scholar databases from January 2000 to December 2024. Search terms included marginal ulcer, anastomotic ulcer, gastric bypass, refractory ulcer, surgical treatment, vagotomy, and revisional surgery. We focused on studies reporting surgical outcomes for refractory MU after RYGB. Results: Current surgical options include (1) gastrojejunostomy revision with or without pouch reduction, (2) truncal vagotomy (laparoscopic or thoracoscopic), (3) subtotal or total gastrectomy with esophagojejunostomy, (4) gastric remnant resection, and (5) RYGB reversal with or without conversion to sleeve gastrectomy. Reported success rates vary from 36% to 100% depending on technique and follow-up duration. Recurrence rates remain concerning, ranging from 15% to 57% at 1 year. Risk factors for recurrence include persistent smoking (HR: 5.03), immunosuppression (HR: 4.60), and Nonsteroidal anti-inflammatory drug (NSAID) use (HR: 3.11). Emerging endoscopic approaches, including suturing and stent deployment, show promise as step-up therapy before surgical revision. Conclusions: The management of refractory MU after RYGB remains challenging with no single optimal surgical approach. Treatment should be individualized based on ulcer characteristics, the presence of associated complications (gastrogastric fistula and stricture), and patient risk factors. A stepwise algorithm incorporating endoscopic therapy, gastrojejunostomy revision, and salvage procedures is proposed.

BACKGROUND Sleeve gastrectomy (SG) is widely used in obesity treatment, although it is associated with new onset of gastroesophageal reflux disease (de novo GERD) and weight regain. Roux-en-Y gastric bypass (RYGB) is the standard revisional procedure for GERD, though it offers limited additional weight loss. Ileal-based procedures have demonstrated superior outcomes regarding weight loss but have uncertain results in GERD. This study presents preliminary findings on gastric bipartition with functional duodenal exclusion (GBp-FDE) as a revisional approach following SG in this scenario. CASE REPORT A retrospective data analysis was conducted on 10 patients who underwent GBp-FDE due to de novo GERD and obesity recurrence after SG (mean BMI: 37.2±3.2 kg/m²). Nine patients presented with hiatal hernia and 8 with sleeve dilation. GERD was assessed pre- and postoperatively using a validated questionnaire, endoscopy, and contrast radiology. The surgical technique involved a pre-pyloric antroileostomy in Roux-en-Y configuration using a 40% proportion biliopancreatic limb. One-year postoperative findings included pyloric spasm (endoscopy), very preferential contrast flow to the ileum (radiology), and endoscopic access preservation to the duodenum. GERD symptoms resolved in 90% (P=0.0059) and esophagitis healed in 80% (P=0.008), likely due to gastric decompression. Mean percent total weight loss and percent excess weight loss were 35.2±6.6 and 108.0±11.14, respectively. CONCLUSIONS GBp-FDE seems to be a promising surgery for managing de novo GERD and obesity recurrence after SG, through SG pouch decompression and ileal stimuli, promoted by the antroileostomy. Further controlled studies with extended follow-up are necessary to validate these findings.

Background/Objectives: Advancements in surgical stapling devices play a crucial role in improving outcomes for bariatric procedures. This study evaluates the performance and safety of a new endoscopic stapler (EnDrive® Beluga^TM) regarding perioperative results across multiple bariatric surgery types. Methods: A retrospective analysis was conducted on 112 patients who underwent bariatric procedures using the Beluga stapler at two centers in the United Arab Emirates and Kenya over a 6-month period (June-December 2023). Procedures included laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), one anastomosis gastric bypass-mini gastric bypass (OAGB-MGB), and revisions. Perioperative outcomes, complications, and hemoglobin changes were assessed. Results: The cohort included 29 males and 83 females, with a mean age of 32.8 years and preoperative body mass index of 41.1 kg/m². Procedures performed were 88 primary LSG, 3 primary LRYGB, 12 primary OAGB-MGB, and 9 revision surgeries. No conversions, deaths, bleeding, or leaks occurred. Minor complications were observed in 4 patients. One patient required reoperation for intestinal obstruction. The mean hospital stay was 1.5 days. Hemoglobin levels showed minimal change from preoperative (12.8 g/dL) to postoperative day 1 (12.3 g/dL). Conclusions: The new Beluga endoscopic stapler demonstrated safe and effective performance across various bariatric procedures through this retrospective study, with low complication rates and minimal blood loss. Its enhanced articulation capabilities may offer advantages in specific cases. Further studies with larger groups, control groups, and longer follow-up periods are warranted to compare long-term outcomes with established stapling devices.