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Page 2 of 10 Eskander et al. Mini-invasive Surg 2024;8:32 https://dx.doi.org/10.20517/2574-1225.2024.71

Postoperative complications occurred in three patients, with one leak, one peritonitis due to colonic thermic lesion
from adherences, and one postoperative death due to massive pulmonary embolism. Four patients claimed
intractable reflux between 3 and 6 months and were later converted to a Roux-en-Y gastric bypass (RYGB). The
remaining patients experienced complete resolution of reflux symptoms in the 6-month follow-up. The percentage
of excess weight loss (%EWL) was 58.5% on postoperative 12 months.

Conclusions: SLEEVE-DOR with one nonabsorbable barbed suture is a safe, effective, and technically simple
alternative procedure to allow the performance of SG for morbidly obese patients with preoperative mild
symptomatic gastroesophageal reflux, especially for patients with severe obesity as the first step operation.

Keywords: Sleeve gastrectomy, anterior fundoplication, D-SLEEVE, SLEEVE-DOR, barbed suture, gastroesophageal
reflux disease, Barrett esophagus, GERD

INTRODUCTION
Laparoscopic sleeve gastrectomy (LSG) has rapidly become one of the most common bariatric surgeries
[1,2]
worldwide . Several factors have contributed to its increasing popularity, including minimal alterations in
gastrointestinal anatomy, short operative time, and efficacy in weight reduction and resolution of
comorbidities. Despite these advantages, some studies have recently demonstrated that sleeve gastrectomy
(SG) may exacerbate gastroesophageal reflux disease (GERD) symptoms or even increase the risk of “de
[3,4]
novo” postoperative GERD .

For the above-mentioned clinical conditions, many novel methods and solutions have been described and
evaluated in recent years. Initial series using Nissen-Sleeve (N-Sleeve) showed good results for treating and
avoiding gastroesophageal reflux associated with SG . Olmi et al. demonstrated that SG combined with
[5-7]
the modified Rossetti antireflux fundoplication procedure could achieve satisfactory weight loss and
significant improvement of GERD . The percentage of patients with GERD respectively fell to 6.3% and
[8]
1.0% at 6 and 24 months postoperatively. Nevertheless, the techniques involving larger wraps have the
disadvantage of a considerable amount of remaining gastric fundus and inadequate weight loss, and were
also associated with a higher incidence of complications in the literature, including leaks and wrap necrosis
up to 5.6% [9-13] .

A simpler alternative technique, anterior fundoplication SG (SLEEVE-DOR procedure or D-Sleeve), was
first described by Nelson et al. in 2016 [14-16] . With this technique, after the resection of the gastric greater
curvature, the small upper gastric fundus was rotated anteriorly and was sutured to the left- and right-crus
and the arcuate ligament, and 93% cases showed significant improvement of GERD symptoms.
Furthermore, del Genio et al. performed a similar D-SLEEVE procedure in 32 cases and could control and
prevent GERD after surgery . However, although different types of fundoplication have been combined
[17]
with LSG to control and/or prevent the GERD after SG, the role for these technical refinements is still
controversial.

In the present study, our research group describes a larger series of SG combined with 180-degree anterior
fundoplication (SLEEVE-DOR) using a simplified technique with only one barbed suture, and evaluated its
safety, feasibility and efficacy for the therapy of morbidly obese patients accompanied with symptomatic
GERD.