Demographics:

• Patient CMC

• Female

• 45 years old

• Weight—103 Kg

• Height—1.52 m

• BMI on revision—44.5 Kg/m²

• History of progressive obesity for the last 8 years

• Laparoscopic Sleeve Gastrectomy 5 years before reintervention

• BMI on first surgery—41.2 Kg/m²

• Nadir—33.5 Kg/m² (9 months after sleeve)

• Started weight regain on the second year after surgery.

Patient’s habits

• Social alcoholism

• No smoking

• No physical activity.

• Food habit—preference for sweets

• Tried some medications after weight regain (Sibutramine, Topiramate).

Current Comorbidities:

• Hypertension in the last 4 years—Amlodipine 10 mg a day

• Sleep Apnea

• Moderate Hepatic Steatosis

• Dyslipidemia

• GERD—pyrosis, regurgitation and dysphagia (validated questionnaire). developed after primary operation (“De Novo GERD”)

• Previous laparoscopic SG (8 y ago)

• Previous laparoscopic hysterectomy (4 y ago)

• Three cesarean sections

Family History:

• Obesity history—father’s and mother’s family

• Hypertension—father’s family

Preoperative workup

§ Preoperative UPPER DIGESTIVE ENDOSCOPY:

• Axial hiatal hernia—4 cm

• Erosive esophagitis grade B (LA classification)

• Sleeve tube dilation, allowing retroflexion (approximately 6 cm wide)

• Enlarged hiatus

• Mild pangastrites

• Histopathology—chronic active gastritis/H. pylori-negative

§ Preoperative UPPER RADIOLOGICAL GASTROINTESTINAL CONTRAST SERIES:

• Gastroesophageal reflux

• Moderate hiatal hernia

• Dilated sleeve (more than 350 ml) (Figure 14)

§ Preoperative HRM:

• Hypotonic inferior esophageal sphincter pressure

• Esophageal hypomotility

• Good esophageal functional reserve

§ Preoperative IMPEDANCE-PHMETRY:

• Pathological orthostatic and supine acidic reflux

• DeMeester Score—87.4

§ Preoperative Abdominal ULTRASOUND:

• Hepatic steatosis grade II

• Hysterectomy

§ Preoperative POLYSOMNOGRAPHY:

• Moderate sleep apnea

§ Preoperative LABORATORY TESTS:

• B12, Vitamin D and Zinc deficiencies (supplemented)

• Glycemia—112 mg/dl, HbA1c—6.0 (Metformin 850 mg)

• Total Cholesterol—260 mg/dl, Triglycerides—210 mg/dl

• 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 06/30/22;

• Surgical time—145 min;

• Length of hospital stay—24 hours;

• Uneventful postoperative recovery.