AJYR+GV vs RYGB for GERD

Bariatric surgery is the treatment of choice for clinically severe obesity. Among thesurgical options, Roux‐en‐Y gastric bypass (RYGB) remains one of the most frequentlyindicated techniques. Despite the advantages of this operation ‐ namely, its control ofgastroesophageal reflux (GER), its satisfactory and durable weight loss, and itsfavorable metabolic effects ‐ one must consider the creation of excluded gastrointestinalsegments that it promotes, rendering them inaccessible to peroral endoscopy, particularlythe excluded stomach, the duodenum, the biliary tract, and the pancreatic ducts. Thesedrawbacks may contraindicate RYGB in certain specific situations. Maintaining thebeneficial effects of RYGB while avoiding digestive exclusions and preserving peroralendoscopic access to the biliopancreatic ducts would add advantages to this surgicalmodel.With regard to sleeve gastrectomy (SG), its refluxogenic potential is widelydemonstrated. However, a series of protective mechanisms against gastroesophageal refluxmay be provided by adding a wide Roux‐en‐Y antrojejunostomy (AJYR) to the gastric tube ofthe SG. Thus, the present project aims to evaluate the effects of AJYR added to SG on GERand to compare them with the antireflux effects produced by RYGB, through a prospective,double‐blind, randomized study that will follow patients with continuous assessments forgastroesophageal reflux disease (GERD). The technique under study would avoid digestiveexclusions and maintain peroral access to the biliary tract and pancreaticducts.Roux‐en‐Y gastric bypass (RYGB), although a well‐established bariatric surgicaltechnique that yields the best results in the treatment of gastroesophageal reflux (GER)in patients with obesity, leads to gastroduodenojejunal and biliopancreatic exclusion,rendering these segments endoscopically inaccessible on routine peroral endoscopy. Theselimitations can be highly relevant in certain groups of patients, which couldcontraindicate the use of this technique on various occasions. Accordingly, and with thepurpose of overcoming these limitations of RYGB, we seek to evaluate a technicalmodification of sleeve gastrectomy (SG) that could reproduce the beneficial effects ofRYGB in controlling GER, yet without promoting digestive exclusions or preventing peroralendoscopic access to the biliary tract and pancreatic ducts. These results are intendedto be achieved by adding a wide Roux‐en‐Y antrojejunostomy (AJYR) to the anterior antralwall of the gastric tube of the SG. Possible mechanisms of action that would justify AJYRcombined with SG in controlling gastroesophageal reflux disease (GERD) would be: (1)caudal traction of the gastric tube by the antrojejunal anastomosis, helping to fix itbelow the diaphragm and keep it straightened; (2) a long, narrow gastric tubedecompressed by a wide AJYR, decreasing intragastric pressure, facilitating distal foodflow, and reducing proximal reflux of acidic content through the cardia; and (3) improvedgastric emptying through the wide AJYR, leading to reduced gastric stasis. Thus,confirmation of the hypotheses that the adoption of AJYR combined with SG reduces theoccurrence of GERD more effectively than RYGB, and that it directs the main food flow tothe jejunal limb, may represent an important surgical alternative for resolving some ofthe obstacles related to the use of RYGB, improving the benefits of this technique.