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Eskander et al. Mini-invasive Surg 2024;8:32 https://dx.doi.org/10.20517/2574-1225.2024.71 Page 3 of 10

METHODS
Study design
This is a prospective, non-randomized study. Between June 2018 and July 2023, patients with obesity
accompanied by mild symptomatic gastroesophageal reflux candidates to LSG with SLEEVE-DOR were
consecutively included in this study. All eligible patients had well-controlled GERD [permanent proton
pump inhibitor (PPI) therapy; 1-2 times, 40 mg/day; at least for the last 6 months], which was
preoperatively confirmed via esophagogastroduodenoscopy. Exclusion criteria were patients with
preoperative Barrett esophagus, large hiatal hernia more than 3 cm in diameter, severe esophagitis Grade C
of Los Angeles and higher and GERD with conservative criteria of need for chronic medication. The
informed consent was preoperatively signed and attained from all patients, and the present protocol was
approved by the local ethics committee (EA1/193/16) and performed in accordance with the ethical
standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical
standards.

All clinical data of eligible patients were collected from our Bariatric and Metabolic Center database in
Potsdam-Germany. The follow-up information was obtained via regular visits in the outpatient clinic at
intervals of every 3 months. PPIs were prescribed for 60 days postoperative and then interrupted.

The primary outcomes of the study were technical success, perioperative complications and mortality, and
the resolution of the symptomatic gastroesophageal reflux after SLEEVE-DOR. The second outcome was
the percentage of excess weight loss (%EWL). Weight loss is expressed as %EWL and percentage of total
weight loss with the calculation of ideal weight as that equivalent to a body mass index (BMI) of 25 kg/m
2
2
and percentage of excess BMI loss with excess BMI > 25 kg/m .
Surgical technique
Laparoscopic SLEEVE-DOR procedure [Figures 1 and 2]
Under general anesthesia, patients were placed in the supine position with intubation. Prophylactic
antibiotics [single shot of antibiotic (1 g sulbactam + 2 g Ampicillin)] were given at the induction of the
anesthesia, and a sequential compressive system (Medtronic) was applied to both legs. The surgeon stood
on the right side of the patient, while the first assistant (camera assistant) was on the left side. The legs of the
2
patients were not spread. Five trocars were inserted after intraabdominal CO insufflation [Figure 3A]. SG
was performed in the usual technique using the Thunderbeat device (Olympus, Hamburg, Germany) by
separating the greater omentum from the greater curvature of the stomach 3 cm from the pylorus all the
way up to the angle of His, to expose the left and right crus. Hiatal hernia was checked and only dissected
and repaired when present using 2/0 barbed nonabsorbable V-Loc running suture (Covidien, Mansfield,
MA) with a 36 French calibration bougie. The greater curvature was stapled beginning from 3 cm oral to the
pylorus until 4 cm from the gastroesophageal junction [Figure 3B]. At this point, the stapling line was
directed to a 45-degree deviation to the left of the patient (no longer following the bougie), resulting in a
flap of gastric fundus of around 3 cm distance from the gastroesophageal junction. A methylene blue test
was performed before fundoplication. Subsequently, an anterior 180-degree fundoplication was conducted
by suturing the resulting gastric fundus to the right crura. Typically, one barbed running suture (V-LOC 2-
0, nonabsorbable) was placed from the remaining fundus to the right crus. Subsequent stitches using the
same suture secured the crura at first 1cm and, in aboral progression, also fixed it to the anterior wall of the
sleeve [Figure 3C]. The fundic wrap was not sutured to the esophagus, and the fundoplication was
performed over the 36Fr bougie. Finally, the resected stomach was removed through a 12 mm trocar site
[Supplementary Film 1]. In cases where a gastroscopy was performed, usually 3 months later, the results
showed an adequate anterior fundoplication [Figure 3D].