Combined Re-sleeve and Single Anastomosis Sleeve Ileal (SASI) Bypass as a Second Stage After Sleeve Gastrectomy (Video Report)

Background In comparison with purely restrictive procedures, combined restrictive and malabsorptive procedures seem to produce better weight loss and comorbidity control in patients with morbid obesity. Two-stage bariatric surgery is popular and is a safe and efficient strategy for patients with super obesity (BMI > 50 kg/m 2 ) and super-super obesity (BMI > 60 kg/m 2 ). Methods The patient in this video was a 36-year-old man with an initial BMI of 53.2 kg/m 2 . Two-stage bariatric surgery was planned. The patient underwent the first stage, laparoscopic sleeve gastrectomy, in 2018. Eighteen months after surgery, his lowest BMI was 38.8 kg/m 2 , and his excess weight loss was 50.9%. In 2021, he regained weight and reached a BMI of 42.4 kg/m 2 . Then, a second-stage bariatric surgery was performed. Results As shown in the video, combined re-sleeve and single anastomosis sleeve ileal (SASI) bypass constituted the second stage of bariatric surgery. During the operation, adhesiolysis was first performed, and the stomach was mobilized through a lateral-to-medial approach. Gastric transection was performed with a 36-Fr bougie. Then, the ileocecal junction was identified, and a location 250 cm from the cecum was selected as the anastomosis site. Gastro-ileal anastomosis (3 cm in diameter) was established with a stapler, and the two-layer suture method was used to close the defect. The postoperative period was uneventful, and the patient was discharged 5 days after surgery. Conclusions Combined re-sleeve and SASI bypass has a few surgical morbidities and is promising as an alternative to second-stage duodenal switch in patients with super obesity.