Demographics:

● Patient CMSF;

● Female;

● 39 years old;

● Weight: 116 Kg;

● Height: 1.66 m;

● BMI: 42.1 Kg/m²;

● History of progressive obesity for the last 15 years.

Patient’s habits:

● No alcoholism or smoking;

● No physical activity;

● Food habits: Preference for pasta and sweets;

● Several previous attempts to lose weight, with nutritional counseling and use of medications (Sibutramine, Liraglutide, Orlistat).

Comorbidities:

● Hypertension in the last 3 years: Losartan 50 mg BID;

● Diabetes in the last 5 years Vildagliptin 50 mg + Metformin 1000 mg;

● Mild sleep apnea;

● Steatosis grade II;

● Hypercholesterolemia: Rosuvastatin 20 mg;

● GERD: Weekly symptoms (pyrosis and regurgitation): Validated questionnaire;

● Left knee arthropathy;

● Laparoscopic appendectomy 8 years before;

● Two cesarean sections.

Family history:

● Morbidly obesity: Maternal uncle;

● Obesity: Mother and sister;

● Hypertension: Father;

● Diabetes: Mother;

● Family history of cancer: Gastric cancer (mother), pancreatic cancer (maternal uncle).

Preoperative workup:

● Preoperative UPPER DIGESTIVE ENDOSCOPY:

● Hiatal hernia grade I (20 mm);

● Erosive esophagitis grade B (LA classification) ;

● Mild pangastritis;

● Histopathology: Chronic active gastritis/H.pylori-negative.

● Preoperative SERIOGRAPHY:

● Short hiatal hernia with documented gastroesophageal reflux.

● Preoperative MANOMETRY:

● Inferior esophageal sphincter hypotony;

● Normal esophageal motility;

● Good esophageal functional reserve.

● Preoperative IMPEDANCE pHmetry:

● Pathological orthostatic and supine acidic reflux;

● DeMeester Score: 79.4.

● Preoperative ULTRASOUND:

● Steatosis grade II.

● Preoperative POLYSOMNOGRAPHY:

● Mild sleep apnea.

● Preoperative LABORATORY TESTS:

● Blood glucose: 165 mg/dl HbA1C: 7.8%/GADA and ICA negatives;

● Iron and Vitamin D deficiencies (supplemented);

● Total cholesterol: 250 mg/dl LDL: 135 mg/dl/HDL: 37 mg/dl;

● AST: 65 UI/L ALT: 89 UI/L;

● Other laboratory tests were normal.

Other information:

● Pre op workup ok, with due care;

● Pre op multidisciplinary team counseling;

● Proposed surgery: Sleeve gastrectomy;

● Surgery performed on 01/15/20. Surgical planning modification occurred, due to unexpected intraoperative finding (subserosal, 0.5 cm diameter, pre-pyloric nodule, on the anterior wall). No frozen biopsy available. Sleeve gastrectomy and lesion resection, with 2 cm safety margin, was performed. A Roux-en-Y gastrojejunostomy was added in the site of the resected lesion. There were no intercurrences during the procedure;

● Surgical time: 95 min;

● Length of hospital stay: 24 hours;

● Uneventful postoperative recovery;

● Histopathology: Schwannoma.

Second postoperative year:

● Weight loss: 51 Kg;

● %TWL: 43.96%;

● No diabetes medications, since hospital discharge;

● No antihypertensive medications, since the fourth postoperative month;

● Sleep apnea resolution;

● Free of GERD symptoms;

● No steatosis;

● Good nutritional status;

● Endoscopy: No hiatal hernia/no esophagitis/well-formed wide antrojejunal anastomosis, 1 cm proximal to the pylorus (Figure 1);

● Seriography: No hiatal hernia/no gastroesophageal reflux/very preferential flow to the jejunum (Figure 2).