| Abstract: |
Obesity is now a worldwide pandemic with increasing prevalence as defined by the world health organization. Among all the approaches for management of obesity, bariatric surgery has proven to be the most effective long-term solution to the problem
Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure worldwide. LSG replaced Roux-en-Y gastric bypass (RYGB) as the most common bariatric procedure worldwide in 2014.
LSG success stems from – in addition to excellent weight loss and remission of most obesity-related comorbidities - being less morbid than some of the other bariatric operations, such as laparoscopic RYGB, because of its technical simplicity and limited alteration of the normal anatomy.
However, our understanding of digestive physiology is changing. We now have increasing awareness of the role of neuroendocrine signals in the regulation of satiety, food intake and weight loss. The most important of these postprandial neuroendocrine signals are an elevation of satiety gut hormones in the blood, such as GLP-1, PYY and a reduction of ghrelin, an orexigenic hormone mainly produced by neuroendocrine cells mostly located in the gastric fundus. Therefore, while LSG was initially regarded as a purely restrictive procedure, we now know that it also promotes weight loss by inducing anorexia through removal of the majority of ghrelin-producing cells.
Santoro concluded that most patients with obesity present with an attenuated and delayed intestinal satiety because they have a diminished secretion of distal gut hormones after meals (e.g., GLP-1). So, he reported his Santoro’s operation: a sleeve gastrectomy with transit bipartition (SG + TB). SG + TB amplifies the nutritive stimulation of the distal gut whereas simultaneously diminishing the exposure of the proximal bowel to nutrients without completely deactivating duodenum and jejunum.
Mahdy popularized a modification of Santoro’s procedure by performing a loop rather than Roux-en-Y bipartition reconstruction in 2015, which came to be known as (Single Anastomosis Sleeve Ileal “SASI”) bypass. With the advantage of maintaining the natural pathway through the duodenum where a small percentage of food passes, , and is supposedly associated with less incidence of leakage and gastroesophageal reflux than sleeve gastrectomy, presumably because the gastroileal bypass decreases the stomach pouch pressure.
We designed this trial to test this theoretical advantage of SASI bypass against standard laparoscopic sleeve gastrectomy. We recruited 28 patients for this trial, divided equally and randomly into two groups, each assigned to one of the two operations. We compared both groups regarding demographics, pre-operative characteristics, comorbidities, operative complications and follow up results. This study was carried out under supervision of our bariatric surgery team in GIT and Endo-lap surgery unit. To the best of our knowledge, this was the first prospective controlled trial comparing the outcomes of both procedures.
Overall, both procedures were comparable in results, with no statistically significant difference between them. SASI bypass group showed longer operative time. There were deaths (two cases) on the SASI bypass group only. The differences were not statistically significant.
As for weight loss, the results were very close in both %EWL and %TWL along the 2 years follow up period. While the results are still not statistically significant, it is noted that the overall weight loss was also noticeably less than reported in most other studies (>80 -90 % EWL). Moreover, the other studies did not continue the follow up after 12 months. A larger sample with longer follow up is necessary to corroborate these observations.
The BAROS score, which is the most recognized standardized system for evaluating and comparing outcomes of bariatric procedures or other weight loss methods, combining weight loss, complications and quality of life assessment into a single scoring system, was applied on our patients. As far as we know, it was never applied in the previous studies. Similarly, it showed no significant difference.
Therefore, we recommend:
• further investigation and replication of clinical trials to iron-out the technical details of the operation i.e., size of the bypass stoma, length of the common limb.
• Further quantification of its morbidity, complications and superiority in terms of weight less needs further proof.
• Comparison of the procedure with RYGB, the gold standard for bariatric surgery
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