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V.V. Evdoshenko

JSC Institute of Plastic and Cosmetic Surgery;
Pirogov Russian National Research Medical University

V.V. Fedenko

JSC Institute of Plastic and Cosmetic Surgery

N.S. Bordan

JSC Institute of Plastic and Cosmetic Surgery;
Pirogov Russian National Research Medical University

N.L. Matveev

Pirogov Russian National Research Medical University

A.S. Tsepkovsky

Pirogov Russian National Research Medical University

One-anastomosis gastric bypass with a short limb

Authors:

V.V. Evdoshenko, V.V. Fedenko, N.S. Bordan, N.L. Matveev, A.S. Tsepkovsky

More about the authors

Journal: Pirogov Russian Journal of Surgery. 2020;(11): 37‑47

Views: 11518

Downloaded: 295


To cite this article:

Evdoshenko VV, Fedenko VV, Bordan NS, Matveev NL, Tsepkovsky AS. One-anastomosis gastric bypass with a short limb. Pirogov Russian Journal of Surgery. 2020;(11):37‑47. (In Russ., In Engl.)
https://doi.org/10.17116/hirurgia202011137

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Introduction

Up until now, the indications for surgical treatment of obesity, first stated by the National Institute of Health (NIH) in 1991 [1], then adapted by the International Federation for the Surgery of Obesity (IFSO) in 1997 [2], and then updated in NIH clinical guidelines in 1998 [3], have not changed significantly.

However, the rapid development of bariatric surgery into a safer and more effective surgical modality has created steady trend towards increased application of bariatric surgery in patients with borderline formal indications of obesity, or even slightly below them.

It is known that the formal indications for bariatric surgery are applicable to any surgical modality and every patient, and those who meet the appropriate IFSO criteria can undergo any bariatric operation, from gastric banding to biliopancreatic diversion. However, in real life, the choice of operation always depends on the patient’s weight and comorbid pathology. That is primarily due to the fact that different bariatric operations have different degrees of influence upon the metabolic process, different complications and, lastly, different efficacy.

The greatest effectiveness in terms of weight loss and regression of obesity-related diseases requires major surgery which, of course, is associated with a greater likelihood of developing all kinds of surgical complications and metabolic disorders in the long term. Conversely, a less invasive operation that does not involve the bypassing of part of the small intestine always appears to be safer and, although less effective, is offered to patients who have only initial or even relative indications for the need for bariatric surgery.

Objectives

The aim of our study was to develop a method for the surgical treatment of patients with obesity ranked in the first and second class, which meets the following criteria:

— high safety;

— sufficient efficacy;

— the absence or minimization of malabsorption;

— absence of restrictions in postoperative examination of the gastrointestinal tract;

— no need for resection and removal of organs;

— reversibility if necessary.

Patients and methods

In the course of studying literature and based on first-hand experience (at least 5000 bariatric operations since 1999), we have come to the conclusion that to fully meet the above criteria, one of today’s bariatric operations, namely One Anastomosis Gastric Bypass (OAGB), should to be modified.

We performed a series of operations based on a new technique developed by us, the essence of which is the formation of a narrow and long pouch from the lesser curvature of the stomach, the distal end of which was anastomosed with the initial part of the jejunum 20 cm from the Treitz ligament (Fig. 1).

Fig. 1. Gastric bypass with one retrogastric retrocolic anastomosis on a short loop.

From June 2019 to March 2020, we operated on 16 patients (15 women and one man) aged between 23 and 48 years. The average patient weight was 86.12 kg (62 to 124 kg). The average BMI was 35.15 kg / m2 (21.96 to 39.62). Four patients were operated on after a previous gastric banding. In all cases, the decision to remove the band and alter it to another form of bariatric surgery was made on the basis of patients' loss of weight control and steady weight gain despite of conservative measures (restrictive diet and physical activity). The average BMI for the group of patients who underwent band removal and this new surgical procedure was 26.16 kg / m2. The average BMI in a group of 11 patients who underwent primary surgery was 33.71 kg / m2. One of the patients in this group had a Situs Viscerum Inversus Totalis.

All operations were performed by laparoscopic access using a high-resolution video system. To create the pouch, stapling/cutting devices with an electric drive were used. During operations, mono— and bi-polar electrocoagulation with an energy metering control system was used, as well as an ultrasound-power instrument.

The transection of the stomach was carried out from the side of lesser curvature 3 cm from the pylorus. For the first firing, a black reload with 5.0 mm high titanium staples was always used. The use of such a reload is necessary to avoid incorrect stapling due to the significant thickness of the muscle layer of the stomach wall in the pyloric region. The firing was done in a direction almost perpendicular to the lesser curvature, producing a 45 mm staple suture. At the same time, a mandatory control of the residual lumen from the side of the greater curvature was carried out to avoid narrowing of the residual stomach. Further, the vertical stapling of the stomach along the lesser curvature was carried out as close as possible to a 33 Fr calibration bougie. This transection was carried out with the sequential use of reloads with different staple heights, depending on the thickness of the stomach. As a rule, the height of the staples decreased as it moved toward the angle of His.

To create a gastrojejunoanastomosis, a gastric pouch was passed behind the stomach and transverse colon, through the window in the mesentery of the latter. To create such a window, we transferred the patient to a horizontal position and moved the greater omentum together with the transverse colon upward, exposing the mesentery root. The hole was formed 2–3 cm above the Treitz ligament.

As preparation for the anastomosis, we cut off the first perpendicular part of the staple line on the pouch using a monopolar endosurgical hook. After that, the first portion of the jejunum was identified at the distance of approximately 20 cm from the Treitz ligament. The 40 mm incision was made along the antimesenteric edge, corresponding in size to the previously created opening at the distal end of the gastric pouch.

Gastrojejunostomy was made "end-to-side" fashion with a manual continuous suture. The posterior and anterior walls of anastomosis were formed separately using two monofilament resorbable sutures 3-0 (USP). To control the patency and impermeability of the anastomosis, a gastric tube was introduced and a methylene blue solution was injected into the lumen of the anastomosis. After the test, a visual revision of the entire staple suture on the stomach, as well as the anastomotic manual suture, was performed.

After the anastomosis was finished, the window in the mesentery of the transverse colon was closed by applying a continuous suture between the edges of the opening and the wall of the gastric pouch. The Peterson's space (between the mesentery of the transverse colon and small intestine) was sutured tightly using a similar suture material. The operation area was drained with a 5 mm silicone tube to control bleeding. The gastric tube was removed immediately after surgery.

Many criteria have been proposed for the subjective assessment of patients' symptoms of gastroesophageal reflux disease (GERD), but they are all developed for non-operated-on patients. Nevertheless, for the initial assessment of possible jejunogastroesophageal reflux in patients after surgery, we have chosen, in our opinion, the most appropriate questionnaire compiled on the basis of the recommendations of the modern international consensus of gastroenterologists, known as the Montreal Definition, which distinguishes heartburn and regurgitation as the main clinical symptoms of GERD. [4]. The chosen questionnaire (GerdQ) has shown high sensitivity and specificity during a large multicenter study, with good correlation with the data of intraesophageal manometry, PH-metry, and esophagogastroscopy [5].

The GerdQ questionnaire [5] includes six questions to identify reliable predictors of GERD. Among the positive predictors were the presence of heartburn and regurgitation (according to the Montreal Definition), sleep disturbance due to the development of nocturnal regurgitation, and the frequency of patient’s taking antacids. In addition to positive predictors, the questionnaire included two negative ones: nausea and epigastric pain. The patients may confuse these symptoms with heartburn and regurgitation and, rather, their presence indicates the absence of GERD.

The maximum number of points, according to GerdQ, is 18. A significant probability of developing complications associated with gastroesophageal reflux, according to the authors of the method, exists in patients who scored 6 points or more. The survey takes into account the symptoms that have appeared during the previous week.

To assess the results of treatment, we used the method of periodic survey of the operated-on patients. To obtain the objective data, laboratory methods, fluoroscopy and esophagogastroduodenoscopy were used.

Results

The mean duration of laparoscopic gastric bypass surgery according to the method described above was 60 minutes (range 45 to 90 minutes).

During the course of the study, we modified the standard OAGB technique. As the surgeries were performed on patients who were overweight or had 1st or 2nd class obesity, we decided to enhance the restrictive effect of the operation by creating the longest and narrowest gastric pouch possible, which was done by cutting the stomach directly above the pylorus and using the 33 Fr bougie for calibration of the pouch diameter.

Because there is an increase in the length of the gastric pouch during gastric bypass surgery with one anastomosis, in addition to enhancing the restrictive effect it is also a preventive measure against the development of bile reflux. So, we decided to abandon the stapling technique of anastomosis. It is known that during formation of the stapled anastomosis, a stapling device creates a "side to side" anastomosis between the gastric pouch and the jejunum. The jaw of the stapler is inserted into an opening in the posterior wall of the gastric pouch parallel to the vertical staple suture. Therefore, the orifice of the stapled anastomosis is always located at least 3-5 cm above the distal end of the pouch. Additionally, in order to avoid the ischemic strip of the gastric wall between the two vertical stapling lines, a stapled anastomosis is avoided. Therefore, to achieve the above-mentioned objectives, the fundamental move was the creation of a uniformly narrow and maximally long gastric pouch. Thus, we decided to create a horizontally oriented manual anastomosis in an “end-to-side” fashion.

In our opinion, this anastomosis is more physiological. The small intestine with such anastomosis is not deformed and does not lose a part of its lumen. The passage of the intestinal contents shall be unhindered on the anastomosis side. The reflux of intestinal contents into the gastric pouch is, of course, possible, but with a normally functioning lower esophageal sphincter this is unlikely. On the other hand, referring to the side-to-side stapled anastomosis, the conditions for the passage of intestinal contents through the lumen of the gastric tube arise in any case.

On average, 4 to 5 reloads with a length of 60 mm each were used for the vertical transection of the stomach. Thus, the total length of the formed gastric pouch was approximately 24 cm, which reduced the likelihood of jejunogastroesophageal reflux (Fig. 2).

Fig. 2. Scheme of hardware side-to-side anastomosis and manual end-to-side anastomosis.

The duration of hospital stay for all patients was two days. The drainage tube for the surgery area to control possible bleeding from the staple line was removed on the second day after surgery. During the operation, and during the entire period of hospital stay, as well as after discharge from the hospital, no complications were recorded. All patients received the usual recommendations for gastric bypass surgery on nutrition, intake of vitamins and microelements, as well as periodic laboratory tests. All patients were prescribed anticoagulants for prophylactic purposes for up to four weeks after surgery.

As the first one anastomosis gastric bypass surgery with a very short limb was performed by us in June 2019, we have been restricted to using solely the data we obtained three and six months after the surgery. Three months after the surgery, when conducting a routine survey of patients, we used the GerdQ questionnaire.

After three months, during a survey of all 16 patients, we obtained the following data (Table 1).

Table 1. GerdQ questionnaire data in 3 months after surgery

GerdQ questionnaire

1) How often did you have a burning feeling behind your breastbone (heartburn)?

2) How often did you have stomach contents (liquid or food) moving upwards to your throat or mouth (regurgitation)?

3) How often did you have pain in the centre of the upper stomach?

4) How often did you have nausea?

5) How often did you have difficulty getting a good night’s sleep because of your heartburn and/or regurgitation?

6) How often did you take additional medication for your heartburn and/or regurgitation, other than what the physician told you to take) (such as Tums, Rolaids, Maalox)?

1

2

3

4

5

6

Patients

General score

Positve Predictors

Negative predictors

Positive predictors

1

6

0

0

3

3

0

0

2

6

0

0

3

3

0

0

3

9

0

3

3

3

0

0

4

6

0

0

3

3

0

0

5

6

0

0

3

3

0

0

6

6

0

0

3

3

0

0

7

6

0

0

3

3

0

0

8

4

0

0

1

3

0

0

9

6

0

0

3

3

0

0

10

6

0

0

3

3

0

0

11

6

0

0

3

3

0

0

12

3

0

0

3

0

0

0

13

5

1

0

2

2

0

0

14

6

1

0

1

2

2

0

15

6

0

0

3

3

0

0

16

6

0

0

3

3

0

0

As shown in the table, only one of operated-on patients had the initial signs of GERD, namely systematic regurgitation of gastrointestinal contents. This patient had a conversion of gastric banding into OAGB with a short limb. Examination of this patient three months after the operation revealed the signs of a hiatal hernia, which had not been diagnosed earlier. It was decided to perform cruroraphy and esophagophrenopexy. The operation went without complications; the patient did not report any signs of regurgitation in the early postoperative period.

Six months after the operation, along with the assessment of reflux symptoms, we also evaluated the first data on the reduction and stabilization of the patient's weight (Table 2).

Table 2. Questionnaire data in 6 months after surgery

Patients

W

H

EW

BMI

W in 6 months

BMI in 6 months

WL

EWL%

1

94

1,6

30,0

36,7

60

23,4

34

113,3

2

104

1,68

33,4

36,8

65

23,0

39

116,6

3

72

1,65

3,9

26,4

68

25,0

4

101,6

4

68

1,58

5,6

27,2

54

21,6

14

250,4

5

104

1,62

38,4

39,6

64

24,4

40

104,2

6

96

1,74

20,3

31,7

69

22,8

27

132,9

7

95

1,68

24,4

33,7

75

26,6

20

81,8

8

81

1,61

16,2

31,2

64

24,7

17

105,0

9

89

1,63

22,6

33,5

61

23,0

28

124,0

mean

89,2

1,60

21,7

33,0

64,4

23,8

24,8

125%

Note. W — patient's weight before surgery in kg; H — patient's height, meters; EW — excessive weight before surgery, kg; BMI — body mass index before surgery, kg/m2; W in 6 months — patient's weight 6 months after surgery, kg; BMI in 6 months — body mass index 6 months after surgery, kg/m2; WL — weight loss, kg; EWL% — excessive weight loss.

As shown in the table, all the patients achieved normal BMI in 6 months after surgery. Mean BMI in this group of patients was 23,8 in 6 months after surgery, what is in the middle of normal values. The minimal excessive weight loss was 81,8%, and mean EWL was 125%.

Control esophagogastroduodenoscopy was performed in five patients more than six months after the operation. No stagnant fluid and bile were found in the esophagus and the upper section of the gastric pouch. A significant amount of bile in the distal part of the gastric pouch and in the anastomotic area was also not detected. In the course of all studies, it was possible to inspect the esophagus, the gastric pouch along its entire length, the initial part of the jejunum, and also to pass the endoscope retrograde and examine the entire duodenum, the pylorus and the excluded part of the stomach up to the region of its fundus, which is impossible with all other kinds of bypass bariatric operations (Fig. 3).

Fig. 3. Esophagogastroscopy and retrograde duodenogastroscopy.

Additionally, during the retrograde duodenoscopy we were able to visualize the papilla major in all cases. Moreover, in all cases it was very comfortably positioned for possible cannulation using a standard direct view flexible endoscope (Fig. 4).

Fig. 4. Retrograde duodenogastroscopy.

1 — major duodenal paiplla; 2 — pylorus (view from the side of duodenal bulb); 3 — stomach antrum; 4 — stomach fundus.

Discussion

At the time of the approval of the indications for surgical treatment of obesity, only two types of operations performed at that time by the laparotomic approach had been legitimized in the United States: Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass. In Europe, mainly laparoscopic gastric banding and biliopancreatic diversion, also performed with open access, were performed.

All these operations, excluding adjustable gastric banding, were physically traumatic, which made the circle of eligible patients quite narrow. However, although the general recommendations of the IFSO and NIH remained intact, as the impact of bariatric surgery on the course of a range of some chronic diseases had been studied, some notable exceptions have emerged in strict indications for surgical treatment of obesity. For example, there are some reports of the successful use of certain bariatric operations for the treatment of bulimia nervosa [6]. A large body of in-depth studies of the effect of bypass procedures on glucose metabolism, Type 2 diabetes mellitus, became an almost independent indication for the bariatric surgery, regardless (or minimally depending) on the patient's weight [7].

The unique therapeutic properties of mainly bypass operations regarding Type 2 diabetes are reflected in the current recommendations of the International Diabetes Federation (IDF) [8], which allows for the use of bariatric (metabolic) operations for the treatment of diabetes mellitus type 2 in patients with a body mass index of 30 and even (in the Asian population) 27.5 kg/m2. Finally, in 2014, the IFSO formulated its attitude towards the possibility of surgical treatment of patients rated as having first class obesity (BMI 30-34.9 kg / m2), recognizing the formal criterion of body mass index (BMI) as insufficient and not a determining indicator in the choice of treatment for such patients [9].

At almost all stages of the development of bariatric surgery, there were operations that most surgeons performed on relatively "thin" patients. One such example was laparoscopic adjustable gastric banding. At the stage of the formation and widespread adoption of the technique, this type of surgical treatment of obesity seemed safe, reversible and quite effective. The method gained immense popularity all over the world and even in the United States where, in February 2011, the indications for the gastric banding were extended to patients with a BMI of 30 kg / m2 [10].

However, this expansion of indications was belated and rather demonstrated a high demand for a relatively simple and safe method of surgical treatment of obesity in its early stages. It is well known that, having reached its peak in 2008 (about 42% of all bariatric surgeries in the world), by 2011 the share of these procedures in the structure of world bariatric surgery was about 17.8%, and by 2013 — only 10%. [11].

According to the fourth IFSO global registry [12], by 2019 the number of primary gastric bandings in the world was only 3.7% of the total number of bariatric procedures and continues to decline steadily [13].

Such a sharp drop in the interest of the surgical community in this type of operations can be easily explained: of all the initially declared advantages over other bariatric operations, only one remains — it’s relative technical simplicity. With the accumulation of experience, it became obvious that, firstly, the effectiveness of gastric banding decreases over time, and after about 5-7 years there is a relapse back to obesity. Secondly, complications such as dilatation of the esophagus and esophagitis develop [14], nocturnal regurgitation of the esophageal contents into the trachea with the development of aspiration pneumonia [15], and migration of the band into the gastric lumen, requiring a complex procedure for transesophageal endoscopic removal of the system [16].

After the "retirement" of such a popular and minimally invasive method as gastric banding, a huge gap has formed in the arsenal of bariatric surgeons for the treatment of early forms of obesity. We omit the history of short-term use of gastroplication for such patients since this is a topic for a separate study. Suffice it to say that, also, gastroplication did not justify the hopes it might become a method of choice for patients with a low BMI.

Sleeve gastrectomy, having started its triumphant ascent in 2003, very quickly gained a strong position. By 2013, the share of this operation in the global bariatric activity was 37% [11]. According to 2019 data, sleeve gastrectomy is the absolute leader among bariatric procedures in the world, almost twice the numbers for Roux-en-Y gastric bypass surgery, and which accounts for 58.6% of the global volume of surgical care for patients suffering from obesity [13]. Due to it’s relative technical simplicity and good results, this operation quickly gained popularity, not least due also to the general disappointment of surgeons with gastric banding.

Thus, if we discard all sorts of non-standard procedures, from the restrictive interventions in the arsenal of bariatric surgeons there is only one operation left today — sleeve gastrectomy. This in turn means that patients with initial forms of obesity are now being offered this type of surgery as a treatment.

This state of affairs cannot be considered optimal since, according to numerous reliable studies, sleeve gastrectomy has a number of serious consequences. The main problem with this intervention in the postoperative period is the development of gastroesophageal reflux disease (GERD). According to the same 5th global IFSO registry, the number of patients with GERD symptoms a year after sleeve gastrectomy is almost 17% [13]. However, these data should be considered understated, as they are based on information provided by bariatric clinics, and it is likely that not all patients having GERD symptoms report them to their surgeons. Objective studies indicate that symptoms of GERD after sleeve gastrectomy may appear in 58–65% [16–18] of patients, including about 4% with Barrett's esophagus [17]. The same studies reported the presence of pyloric dysfunction and duodenogastric bile reflux in approximately 40% of all patients after sleeve gastrectomy.

In addition, one cannot but recall such a formidable complication of sleeve gastrectomy as the leakage of the staple suture, which can lead to serious consequences and even mortality. The literature contains a large number of reports on the occurrence of leakage after sleeve gastrectomy, and the rate of this complication can vary from 0 to 8% of all operations. Of course, the risk of developing this complication depends on many factors that the authors of a large modern study, involving 1,738 patients, tried to systematize [19], but still the risk of developing failure of the proximal staple suture, according to their data, averages as much as in 2.6% of all operations! In simple terms, this means that for every 100 operations, surgeons are subsequently presented with at least two patients with a serious life-threatening condition. In addition, sleeve gastrectomy is a completely irreversible procedure associated with the removal of an organ, which radically distinguishes it from gastric banding.

Based on this situation, in the last decade, more and more surgeons have opted for single-anastomosis gastric bypass (OAGB), a relatively new operation that, according to its proponents, has several advantages and is devoid of the disadvantages of other bariatric procedures. According to the 5th Report of the Global Bariatric Registry, the share of such operations in the structure of world bariatric activity is already more than 4% [13], which is a considerable number, given that until 2010, OAGB was performed only by enthusiasts [20]. It should also be kept in mind that this type of surgery is still not widely practiced in the United States, which still remains the leader in the global volume of bariatric surgeries. In a large study from Germany, which included more than 15,000 such surgeries, a comprehensive analysis of the new bariatric surgery was carried out. A comparison of its effectiveness in weight loss, the effect on remission of obesity-related diseases, the number of perioperative and long-term complications in relation to Roux-en-Y Gastric Bypass and Sleeve Gastrectomy has been carried out [21].

The study demonstrates better results for OAGB in all of the above parameters. According to this large-scale study, the only factor that could be an important disadvantage of OAGB is the potential for the development of bile reflux into the pouch and the esophagus, by analogy with the Billroth II gastric resection. To prevent the development of duodenogastroesophageal reflux (DGER), the authors recommend creating a pouch at least 15 cm long from the lesser curvature of the stomach [21].

To date, there are only a few reports in the literature on the development of gastric and esophageal cancer after OAGB. The authors of a large review study [22], based on the study of numerous publications, came to the conclusion that the risk of developing cancer after surgery exists in patients who already had GERD symptoms before surgery, or if the patient developed these symptoms as a result of surgery. The presence of bile in the pouch without symptoms of gastroesophageal reflux, according to the authors, has no clinical significance. Another large retrospective study by Italian authors, based on an analysis of 2,678 patients who underwent OAGB surgery in the period from 2006 to 2015, found a statistically significant correlation of cases of postoperative duodenogastroesophageal reflux (DGER) — 4% — with the presence of GERD in patients before surgery or with the formation of a pouch less than 9 cm in length [23]. The same study noted a rather low percentage of early postoperative complications, in particular, the rate of leakage of the staple line of the stomach and gastrointestinal anastomosis in total was only 0.37%.

Thus, it could be considered that the operation of gastric bypass with one anastomosis, being a safe and effective method of surgical treatment of obesity, can be widely used for patients with an initial form of obesity, provided that the recommended parameters of the procedure are used. However, unfortunately and currently, such a recommendation is difficult to make, primarily because despite the relative decrease in the volume of the stomach and the associated restriction, nevertheless, both the inventor of the method and his followers consider the OAGB operation to be a basically malabsorptive operations, which works mainly by reducing absorption in the small intestine [20, 21].

The standard recommendation for OAGB is a biliopancreatic limb length of 200 cm from the Treitz's ligament. But, even with such a relatively short length of the bypassed section of the small intestine, often (about 4% of all cases) there are phenomena of hypoproteinemia, anemia and deficiency of essential vitamins and microelements, which cannot be cured by conservative methods and require some restorative operations. [24, 25].

In addition, a standard OAGB is not devoid of one of the significant disadvantages of any gastric bypass surgery — the impossibility to endoscopically examine the excluded part of the stomach and duodenum. And, although weight loss in itself reduces the risk of developing malignant neoplasms of the gastrointestinal tract, there are still reports in the literature about the development of cancer in the antrum after gastric bypass surgery [26]. Additionally, after bypass surgery, retrograde studies of the common bile and pancreatic duct, as well as endoscopic transduodenal procedures on the major papilla, as well as extraction of calculi from the common bile duct, are impossible using conventional means.

Summarizing our initial experience with OAGB with a very short limb, we can note that the surgical technique developed by us is suitable for the surgical treatment of patients with first— and second-class obesity, since it does not carry high risks of developing formidable complications and is a completely reversible operation.

When interviewing past patients three and six months after their operation, we rarely encountered complaints of dysphagia, heartburn and regurgitation. The only patient who experienced regurgitation after a meal (and only when moving to a horizontal position) was operated on for a hiatal hernia not diagnosed before bariatric surgery, after which the symptoms of regurgitation disappeared. None of the 16 operated patients in the course of the survey complained of any phenomena or sensations that could decrease the quality of life. In contrast, significant weight reduction or stabilization contributed to high levels of treatment satisfaction.

We believe that the proposed operation not only doesn’t reduce the quality of life but, in contrast to the conventional OAGB operation, does not reduce the availability of the patient's gastrointestinal tract for routine endoscopic examinations. It is primarily about the possibility of performing control or therapeutic esophagogastroduodenoscopy. We have never encountered technical difficulties while performing this endoscopic examination. In the course of all five upper GI endoscopic studies we performed, we easily examined the esophagus, the gastric pouch formed during the operation, the anastomosis zone, the duodenum, the major duodenal papilla, the pylorus, the antrum and the fundus of the stomach. This possibility, of course, makes the proposed surgery modality safer, since in the case of the development of diseases of the upper gastrointestinal tract and hepatobiliary system, without exception, all diagnostic and therapeutic procedures that are performed by means of intraluminal endoscopy can be used. For example, tumors in all parts of the stomach and duodenum can be detected, biopsied, and excised if required. In addition, if the need arises for diagnostic contrasting of the biliary system, common bile and pancreatic ducts, retrograde cholangiopancreatography (RCP) can be performed. Moreover, catheterization of the major duodenal papilla can be performed with a standard direct view endoscope. This is due to the anatomy of the hepatopancreatoduodenal zone. The retropancreatic part of the common bile duct runs almost parallel to the descending part of the duodenum, then, passing in an oblique direction in its wall, opens into the lumen in the form of a sphincter of Oddi and ends as the major duodenal papilla. The same situation should, in our opinion, make more comfortable, and therefore better, some therapeutic manipulations on the major papilla (for example, papillosphincterotomy), as well as the extraction of calculi from the common bile duct.

We also believe that our proposed One Anastomosis Gastric Bypass surgery with a very short loop can be used as an alternative to sleeve gastrectomy when considering surgical treatment for patients with third-class obesity. That's the opinion we came to on the basis of similarity of weightloss (at least in the initial period), between the proposed technique with the results observed after sleeve gastrectomy. We believe that this fact is explained by the same mechanisms of weight loss in these operations. In both operations, a narrow and long gastric sleeve (named «the pouch» in the case of an OAGB) is created, giving the resistance to the passage of solid food. In both cases, there is no malabsorption effect in the small intestine. Moreover, due to the absence of the pylorus on the path of food after gastric bypass with a short limb, a high-pressure zone is not created in the lumen of the gastric pouch, which means that the risk of developing a leakage of the staple suture is reduced. Therefore, we can make a narrower tube (on a 33 Fr bougie) without the fear of this complication developing.

In our opinion, the proposed operation has other advantages over sleeve gastrectomy: switching off most of the acid-producing zone of the stomach and significantly reducing the likelihood of reflux of acidic gastric contents up to the esophagus; reducing the likelihood of developing a hiatal hernia since the distal end of the gastric pouch is fixed to the initial part of the jejunum by anastomosis. For the same reason, there is a decrease in the likelihood of developing a kinking of the pouch; and finally, and there is full reversibility of the operation because no part of the stomach is removed during a gastric bypass.

Conclusions

The proposed modification of one-anastomosis gastric bypass with a very short limb is a safe and effective kind of bariatric surgery.

This operation provides the possibility to perform postoperative diagnostic and therapeutic endoscopic procedures of the excluded stomach and the duodenum.

After obtaining favourable long-term results, the proposed operation could be recommended for surgical treatment of patients with the first and second class obesity.

The authors declare no conflicts of interest.

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