Demographics:

· Patient MCS

· Female

· 35 years old

· Weight—108 Kg

· Height—1.59 m

· BMI on revision—42.7 Kg/m²

· History of progressive obesity for the last 10 years

· Open Sleeve Gastrectomy 6y before revision

· BMI on first surgery—38.3 Kg/m²

· Nadir—29.5 Kg/m² (1y after sleeve)

· Started weight regain on the third year after surgery.

Patient’s habits

· No alcoholism or smoking

· No physical activity.

· Food habit—preference for snacks and junk food.

· Tried some medications after weight regain (Sibutramine, Semaglutide).

Current Comorbidities:

· Hypertension in the last 2 years—Losartan 160 mg a day

· Snoring

· Moderate Hepatic Steatosis

· GERD—pyrosis and dysphagia (validated questionnaire) developed after primary operation (“De Novo GERD”)

· Previous open SG (6 y ago)

· Previous open cholecystectomy (10 y ago)

· One cesarean section

Family History:

· Obesity history—father’s family

· Hypertension—father and mother

· Gastric cancer—uncle from father’s family

Preoperative workup

§ Preoperative UPPER DIGESTIVE ENDOSCOPY:

· Erosive esophagitis grade A (LA classification)

· Sleeve tube dilation, allowing endoscope retroflexion—approximately 5 cm wide

· Mild antral gastritis

· Histopathology—chronic inactive gastritis/H. pylori-negative

§ Preoperative UPPER RADIOLOGICAL GASTROINTESTINAL CONTRAST SERIES:

· Gastroesophageal reflux

· Dilated sleeve (more than 300 ml) (Figure 1)

§ Preoperative HRM:

· Normal inferior esophageal sphincter pressure

· Normal esophageal motility

· Good esophageal functional reserve

§ Preoperative IMPEDANCE PHMETRY:

· Pathological orthostatic acidic reflux

· DeMeester Score—48.4

§ Preoperative Abdominal ULTRASOUND:

· Hepatic steatosis grade II

· Cholecistectomy

§ Preoperative POLYSOMNOGRAPHY:

· No sleep apnea

§ Preoperative LABORATORY TESTS:

· B12 and Vitamin D deficiencies (supplemented)

· Other laboratory tests were normal

Other information:

· Pre op workup ok, with due care;

· Pre op multidisciplinary team counseling;

· Proposed surgery—Re-Sleeve Gastrectomy with Roux-en-Y antrojejunal anastomosis;

· Surgery performed on 03/02/22;

· Surgical time—125 min;

· Length of hospital stay—24 hours;

· Uneventful postoperative recovery.