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

present study had limited follow-up time to evaluate the real benefit on reflux avoidance and long-term
weight loss. In the current literature for the SLEEVE-DOR technique, one case of a leak, treated
[15]
conservatively, was reported . This innovative surgical method using only one barbed suture to construct
the fundoplication seems advantageous to other techniques and possibly with a shorter learning curve. For
sure, this new technique may not be broadly applied to all patient candidates for SG. In our study, three
patients presented with serious adverse events (SAEs). One patient succumbed to a pulmonary embolism
following subhepatic abscess drainage, another developed peritonitis due to adhesiolysis, and the third had a
leak that was successfully treated.

SLEEVE-DOR is a proposal of a technical change to standard SG, to attempt to attain the lower risk of leak
and better control of GERD symptoms over time. In our study, reflux control was obtained among our
patients on early postoperative time; 95% of the patients attained complete resolution of the symptomatic
GERD at 12 months postoperatively. The technique, by avoiding extensive dissection of the anatomy of
lower gastroesophageal sphincter, represents a simple and effective technique, typically with a low learning
curve. Our study showed few perioperative surgical complications, which were also limited by our sample
size. In our study, the occurrence of leak was 1.3%, lower than in other series using Nissen or Nissen-
Rossetti techniques that required more extensive dissection and larger gastric wraps possibly due to
ischemia. As the mean time before patients developed symptoms of reflux after SG requiring the surgical
[27]
intervention was found to be 33.2 ± 12.5 months , it is possible that longer follow-up time studies may
show lower effectiveness of this technique in avoiding de novo reflux. Nevertheless, the conversion of only
four cases to a gastric bypass is lower than the higher rate found in reoperations for the current sleeve
technique in the literature.

Regarding the techniques used in this study, the indication of whether a laparoscopic or robotic approach
was based on availability of the professional and robotic slots for the operation room. Besides that, patients
with severe obesity were scheduled mostly for a 2-stage laparoscopic procedure. These criteria produced
some bias regarding the comparative results. Robotic surgery was mainly performed by experts and senior
surgeons (authors AT and RZ), and laparoscopic SLEEVE-DOR was mainly performed by younger
surgeons and residents, and the mean BMI was higher for the laparoscopic patients. Possibly for these
reasons, operative times and mean hospital stays were significantly shorter for the robotic approach.

Our study has some limitations; firstly, this study is a prospective documented series with a small sample
size; therefore, comparative randomized studies including more eligible patients and cooperative medical
centers will be needed in the next step. Secondly, the follow-up time of the present study was only 12
months; thus, the information of longer follow-up time is required subsequently, and a routine control
gastroscopy, pH-impedance and esophageal manometry will be performed in 1-year intervals to be reported
in a further study. Subsequently, prospective and randomized control trials are needed to evaluate different
types of fundoplication and try to find adequate responses for this new upcoming issue.

In conclusion, SLEEVE-DOR is emerging as a safe and effective alternative technique to allow the
performance of SG for patients with obesity with preoperative symptomatic gastroesophageal reflux,
especially for patients with severe obesity as the first step operation. Further studies with longer follow-up
time and controlled series compared to current techniques are needed to understand its role, especially
regarding long-term results for GERD.