Bariatric Surgery: Challenges and Future Trends

Dear Colleagues,

I am delighted to welcome you to this Special Issue of the Journal of Clinical Medicine, titled “Bariatric Surgery: Challenges and Future Trends", which particularly focuses on sleeve gastrectomy, its long-term outcomes, and the evolving field of revisional interventions after sleeve gastrectomy.

Sleeve gastrectomy has become the most frequently performed bariatric surgery globally, primarily due to its technical simplicity and strong early results, leading to its widespread acceptance. However, over time, two significant issues have arisen—gastroesophageal reflux (GERD) and weight regain. These concerns are not only clinically important but also increasingly prevalent, highlighting the need for re-evaluation of surgical techniques and the incorporation of new solutions.

This Special Issue explores emerging techniques in order to address pressing challenges. The Nissen-sleeve fundoplication merges the advantages of sleeve gastrectomy with an anti-reflux mechanism of partial fundoplication. This approach is particularly pertinent for patients grappling with obesity and GERD, which frequently coexist and present a treatment challenge. Initial evidence indicates that this method could enhance reflux control without compromising weight loss, thereby presenting a significant opportunity for select patients.

The single-anastomosis sleeve ileum (SASI) procedure is also gaining traction as both a primary and a revisional bariatric option. By uniting the restrictive nature of a sleeve gastrectomy with a malabsorptive ileal bypass in a single anastomosis, SASI yields strong metabolic results while also simplifying the surgical process. Its increasing versatility renders it an appealing choice for various patient demographics, especially those with type 2 diabetes or elevated surgical risks. This trend reflects a broader movement towards physiology-driven, minimally invasive, and reversible interventions.

Revisional bariatric surgery has emerged as a pivotal issue in clinical practice. With a growing number of patients in long-term follow-up after primary sleeve gastrectomy, there is an increasing demand for managing inadequate weight loss, weight regain, or complications related to the procedure. This Special Issue emphasizes the necessity of developing clear, consensus-based definitions and criteria for revisional surgeries to enhance standardization, patient selection, and surgical outcomes.

In the context of revisional surgery, Roux-en-Y gastric bypass (RYGB) distalization is experiencing renewed interest, particularly for patients facing metabolic failure after initial RYGB or as a subsequent intervention following sleeve gastrectomy. Extending the length of the biliopancreatic limb increases malabsorption and further encourages weight loss, albeit at the expense of heightened nutritional challenges. When used judiciously, it provides an effective strategy for metabolic recovery in complex cases.

Collectively, these evolving techniques signify more than just technical advancements; they denote a shift towards personalized metabolic surgery. The future of bariatric care lies in tailored, evidence-based solutions that take anatomical, metabolic, and behavioral factors into account rather than adhering to a one-size-fits-all methodology. As surgeons and clinicians, we bear the responsibility of not only expanding our procedural toolkit but also applying it with precision, foresight, and compassion.

This Special Issue gathers leading thinkers and innovative research to shed light on these advancements and outline a path forward. I encourage you to engage with these contributions, which reflect the dynamic intersection of clinical necessity, surgical creativity, and scientific progress in bariatric surgery.

Dr. Hugo Santos-Sousa
Guest Editor

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• obesity
• metabolic and bariatric surgery
• sleeve gastrectomy
• metabolic syndrome
• novel surgical procedures
• Nissen-sleeve fundoplication
• Roux-en-Y gastric bypass distalization
• single-anastomosis procedures