AJYR+GV vs RYGB for GERD

Bariatric surgery is the treatment of choice for clinically severe obesity. Among the surgical options, Roux-en-Y gastric bypass (RYGB) remains one of the most frequently indicated techniques. Despite the advantages of this operation - namely, its control of gastroesophageal reflux (GER), its satisfactory and durable weight loss, and its favorable metabolic effects - one must consider the creation of excluded gastrointestinal segments that it promotes, rendering them inaccessible to peroral endoscopy, particularly the excluded stomach, the duodenum, the biliary tract, and the pancreatic ducts. These drawbacks may contraindicate RYGB in certain specific situations. Maintaining the beneficial effects of RYGB while avoiding digestive exclusions and preserving peroral endoscopic access to the biliopancreatic ducts would add advantages to this surgical model.With regard to sleeve gastrectomy (SG), its refluxogenic potential is widely demonstrated. However, a series of protective mechanisms against gastroesophageal reflux may be provided by adding a wide Roux-en-Y antrojejunostomy (AJYR) to the gastric tube of the SG. Thus, the present project aims to evaluate the effects of AJYR added to SG on GER and to compare them with the antireflux effects produced by RYGB, through a prospective, double-blind, randomized study that will follow patients with continuous assessments for gastroesophageal reflux disease (GERD). The technique under study would avoid digestive exclusions and maintain peroral access to the biliary tract and pancreatic ducts.Roux-en-Y gastric bypass (RYGB), although a well-established bariatric surgical technique 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. These limitations can be highly relevant in certain groups of patients, which could contraindicate the use of this technique on various occasions. Accordingly, and with the purpose of overcoming these limitations of RYGB, we seek to evaluate a technical modification of sleeve gastrectomy (SG) that could reproduce the beneficial effects of RYGB in controlling GER, yet without promoting digestive exclusions or preventing peroral endoscopic access to the biliary tract and pancreatic ducts. These results are intended to be achieved by adding a wide Roux-en-Y antrojejunostomy (AJYR) to the anterior antral wall of the gastric tube of the SG. Possible mechanisms of action that would justify AJYR combined with SG in controlling gastroesophageal reflux disease (GERD) would be: (1) caudal traction of the gastric tube by the antrojejunal anastomosis, helping to fix it below the diaphragm and keep it straightened; (2) a long, narrow gastric tube decompressed by a wide AJYR, decreasing intragastric pressure, facilitating distal food flow, and reducing proximal reflux of acidic content through the cardia; and (3) improved gastric emptying through the wide AJYR, leading to reduced gastric stasis. Thus, confirmation of the hypotheses that the adoption of AJYR combined with SG reduces the occurrence of GERD more effectively than RYGB, and that it directs the main food flow to the jejunal limb, may represent an important surgical alternative for resolving some of the obstacles related to the use of RYGB, improving the benefits of this technique.

Inclusion criteria

• Candidates for AJYR+SG or RYGB, aged >18 and <65 years
• BMI ≥35 and ≤45 kg/m²
• Presence of gastroesophageal reflux symptoms
• Agreement to randomization between the AJYR+SG and RYGB techniques
• Signed informed consent form (ICF)

Exclusion criteria

• Severe esophageal motor disorders
• Crohn's disease
• Advanced-stage cancer or ongoing cancer treatment
• Failure to undergo the study examinations during follow-up, or withdrawal of informed consent at any time during follow-up (patients will be excluded, and their data analyzed up to the moment of dropout)