Innovative approaches in bariatric surgery: exploring novel techniques and clinical outcomes

Introduction

Obesity, a chronic and multifactorial disease, is projected to increase from a prevalence of 14% in 2020 to 24% within the next 15 years, potentially affecting nearly two billion individuals by 2035 (1). According to a study published in The Lancet, the global age-standardized prevalence of obesity rose from 8.8% in 1990 to 18.5% in 2022 among women and from 4.8% to 14% among men (2). By 2022, an estimated 878 million adults worldwide were classified as obese, with the United States, China, and India reporting the highest absolute numbers of individuals with obesity (2).

Management strategies for obesity include dietary and exercise interventions, pharmacological therapy, and bariatric surgery. Among these, bariatric surgery has demonstrated the most effective long-term outcomes for treating obesity and its associated comorbidities (3). The two most commonly performed bariatric procedures are Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) (4). Compared to RYGB, SG is technically less demanding in surgical technique, has shorter operative times, and reduces the incidence of major complications within 30 days postoperatively (3). However, SG carries higher risks of gastroesophageal reflux, stenosis, and leaks (3-5). At 5 years postoperatively, RYGB has been associated with greater weight loss and higher resolution rates of type 2 diabetes (T2D) and dyslipidemia compared to SG, though there are no significant differences in hypertension and obstructive sleep apnea remission, quality of life, or mortality (3). SG demonstrates lower morbidity compared to RYGB (3).

While several reviews have addressed individual bariatric procedures or compared traditional techniques such as RYGB and SG, few have comprehensively analyzed and compared newer procedures like one-anastomosis gastric bypass (OAGB), single-anastomosis duodeno-ileal bypass with SG (SADI-S), single-anastomosis sleeve ileal bypass (SASI), and SG with transit bipartition (SG-TB) in a unified framework. Existing literature tends to focus on limited outcome metrics or isolated procedures without a systematic discussion of their mechanisms of action, suitability for different patient populations, or long-term efficacy (6). Moreover, inconsistencies in terminology and lack of comparative evaluation have hindered clear clinical guidance regarding these emerging techniques (7-9).

This review seeks to bridge these gaps by providing an up-to-date, structured comparison of these four innovative bariatric procedures, highlighting their surgical principles, metabolic impact, clinical outcomes, and potential advantages over traditional approaches.

OAGB

The OAGB has gained significant popularity as a bariatric procedure and is now widely performed worldwide (10,11). It ranks as the third most commonly performed metabolic/bariatric surgical method, accounting for approximately 4.8% of all bariatric surgeries globally (12,13).

First introduced by Rutledge in 1997 as the mini-gastric bypass, this procedure demonstrated substantial weight loss outcomes in the initial cohort, with an average weight loss of 20% at 1 month, 51% at 6 months, 68% at 12 months, and 77% at 2 years (14). It proved to be both effective and safe, with short operative times, fulfilling criteria for an ideal weight-loss procedure. Additionally, it showed a 70–90% resolution rate for obesity-related comorbidities, comparable to the RYGB and SG (14).

In 2005, Carbajo introduced modifications to the mini-gastric bypass, naming it the OAGB (15,16). These changes aimed to reduce chronic exposure of biliopancreatic secretions to the gastric mucosa by performing a side-to-side gastrojejunostomy rather than an end-to-side anastomosis. Another modification was the fixation of the jejunal loop to the gastric pouch a few centimeters above the anastomosis to prevent gastric pouch dilation and allow biliopancreatic secretions to flow downward toward the gastrojejunostomy (15,16).

Mechanism of action

OAGB facilitates weight loss and metabolic improvements through multiple mechanisms. It includes a restrictive effect via a small gastric pouch that limits food intake and promotes early satiety (16). Additionally, a malabsorptive mechanism arises from bypassing a substantial segment of the small intestine, reducing nutrient and calorie absorption.

However, the primary mechanism of action lies in anatomical alterations that drive neurohormonal signals influencing satiety, rather than mere stomach capacity reduction. Studies suggest OAGB is associated with a greater incretin effect compared to RYGB or SG, evidenced by elevated total insulin secretion levels and improved incretin responses (17,18). In addition, OAGB has demonstrated high rates of T2D mellitus (T2DM) remission, with reported remission rates ranging from 70% to 90% at 1–2 years, attributed to enhanced incretin effects and improved insulin sensitivity (19). Similarly, significant improvements in hypertension have been observed after OAGB, with remission rates reported between 50% and 70% at 1 year postoperatively (20). A randomized controlled trial by Lee et al. comparing OAGB and SG demonstrated enhanced incretin effects with both procedures over a 5-year follow-up. However, OAGB showed superior long-term incretin responses, including earlier peaks in glucagon-like peptide-1 (GLP-1) and insulin secretion postprandially (21).

Surgical technique

Carbajo’s OAGB procedure begins with the creation of a pneumoperitoneum via the left subcostal area. Trocar placement is as follows: a 10 mm trocar in the midline between the xiphoid and umbilicus (camera), a 12 mm trocar 5 cm to the right, another 12 mm trocar 5 cm to the left, a 5 mm trocar in the right flank for liver retraction, and a 5 mm trocar in the left subcostal area 10 cm from the second trocar (15). Dissection begins 3–4 cm proximal to the pylorus to create a 2 cm window into the lesser sac. A linear stapler (45 mm) divides the stomach at the junction of the body and antrum, followed by vertical stapling (60 mm) along the lesser curvature with a 36–40 F bougie as a guide, avoiding the angle of His. A gastrotomy is created anteriorly on the gastric pouch parallel to the staple line. The jejunal loop is identified at the ligament of Treitz, and 200 cm of small intestine is measured. An enterotomy is created on the antimesenteric border of the jejunal loop and brought antecolically.

In Rutledge’s technique, an end-to-side gastrojejunostomy is create, ensuring an isoperistaltic, tension-free anastomosis (14). In Carbajo’s technique, the “anti-reflux system” is constructed by a continuous side-to-side suture between the gastric pouch staple line and the jejunal loop (8–10 cm length), starting 2–4 cm above the stapling line’s end. The gastric pouch’s distal end is then anastomosed to the jejunal loop using a 30 mm linear stapler, and the enterotomy is closed with a continuous absorbable suture (15-22). OAGB is characterized by a relatively short learning curve compared to RYGB, due to the single anastomosis and standardized pouch creation technique. Mastery can often be achieved after 20–30 procedures, making it an accessible option for bariatric surgeons with basic laparoscopic experience (23).

Results

OAGB has proven to be an effective treatment for weight loss. A study on early results published by Rutledge et al., a 12-month follow-up, revealed a mean weight loss of 59 kg, a mean percentage of excess weight loss (%EWL) of 80%, and a mean body mass index (BMI) of 29 kg/m². Weight loss remained within 10 kg of the maximum in over 95% of patients up to 5 years postoperatively (24). Similarly, a study using OAGB as a conversion procedure after SG or laparoscopic adjustable gastric banding showed significant weight loss, with a mean BMI reduction to 31.5%, a mean %EWL of 64.6%, and a mean total body weight loss (TBWL) of 22.5% (25).

OAGB has also demonstrated substantial metabolic improvements. From its early implementation, it achieved diabetes remission rates exceeding 80% (16). In a comparison with laparoscopic SG conducted by Lee et al. in 2014, both techniques achieved similar weight loss percentages (21). However, the OAGB group exhibited lower hemoglobin A1c (HbA1c) levels and higher incretin effects, which were sustained over 5 years (21). Ali et al. [2023] found OAGB to be more effective than SG in terms of weight loss and remission of comorbidities such as dyslipidemia, hypertension, and diabetes mellitus (26). Mujahid et al. reported superior metabolic outcomes with OAGB compared to SG, including statistically significant improvements in total cholesterol, triglycerides, and high-density lipoprotein (HDL) levels (13). Dyslipidemia prevalence was substantially higher in the SG group (55%) than in the OAGB group (25%) (13). When compared to RYGB, OAGB achieved similar weight loss and metabolic outcomes. Robert et al. reported a mean %EWL of 75.6% for OAGB compared to 71.4% for RYGB at 5 years. T2D remission rates were comparable between the groups (18).

Complications

OAGB has demonstrated lower complication rates compared to other bariatric procedures (Table 1). In a 2005 study, Lee et al. compared complications between RYGB and OAGB. Late complications occurred in 3 patients (7.5%) in both groups. In the OAGB group, two patients experienced ulcer bleeding, and one developed ileus (27). Rutledge et al. documented early complications within 30 days in a cohort of 2,410 patients (24). Of these, 142 patients (5.9%) experienced complications. The most common were leaks (1.08%), followed by wound hernias (0.08%) and wound infections (0.12%).

A 2023 systematic review by Balamurugan et al. showed that early complications were most frequent with SADI-S, followed by OAGB and RYGB, whereas late complications were more common with RYGB, followed by SADI-S and OAGB (28). Mortality rates were lowest with RYGB, followed by OAGB and SADI-S. In 2023, Ali et al. reported an increased incidence of gastroesophageal reflux disease (GERD) and leaks in OAGB compared to laparoscopic SG (26). Similarly, Robert et al. identified GERD as the most common adverse event (Table 1), occurring in 41% of patients in the OAGB group compared to 18% in the RYGB group at 5 years (18). Among serious adverse events, 8% of 127 patients underwent revision from OAGB to RYGB, primarily due to anastomotic ulcers, GERD, or both.

The high incidence of clinical GERD following OAGB raises concerns about its long-term effects, warranting further investigation (29).

SADI-S

The SADI-S was first introduced in 2007 by Sánchez-Pernaute as a novel bariatric technique (30). It is based on biliopancreatic diversion with duodenal switch (BPD-DS), involving an SG followed by an anastomosis between the duodenum and an omega loop of the ileum, located 200–300 cm proximal to the ileocecal valve.

A key feature of SADI-S is the preservation of the pylorus and the initial 4 cm of the duodenum, which mitigates complications commonly associated with OAGB (30). In OAGB, direct contact between the gastric mucosa and biliopancreatic secretions can lead to marginal ulcers and bile reflux gastritis. By preserving the pylorus and maintaining the duodenum as the natural conduit for biliopancreatic secretions, SADI-S reduces these risks. Therefore, ensuring the anastomosis is performed on intact duodenal mucosa and preserving the pylorus during the procedure are critical steps (30).

Since its introduction, SADI-S has inspired variations, such as the stomach intestinal pylorus-sparing (SIPS) procedure, which employed a longer common channel but demonstrated similar outcomes. However, the SADI-S has gained wider acceptance and evaluation than its counterparts (31). In 2021, SADI-S received endorsement from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) as a safe and effective procedure, both primary and revisional (32,33). A task force was convened to assess its efficacy and safety, culminating in a 2023 systematic review (32). SADI-S was shown to achieve significant weight loss and sustained control of T2DM in the medium and long term, along with improvements in hypertension and hyperlipidemia. However, frequent nutritional deficiencies were also identified, particularly in fat-soluble vitamins, anemia, and hypoalbuminemia. Despite these findings, high-quality evidence on SADI-S remains limited, highlighting the need for further research and randomized controlled trials, alongside multidisciplinary management for optimal patient outcomes (32).

Mechanism of action

SADI-S combines restrictive and malabsorptive mechanisms to promote weight loss and metabolic improvement. Its dual approach has garnered support from leading bariatric surgery societies, including IFSO and the American Society for Metabolic and Bariatric Surgery (ASMBS), particularly for patients with class IV or V obesity (32-34).

The restrictive component is achieved through SG, which reduces stomach volume, limits food intake, and induces early satiety, playing a significant role in weight loss. The malabsorptive component is accomplished via the duodeno-ileal bypass, which shortens the absorptive surface of the intestine, leading to decreased nutrient and caloric absorption. Additionally, SADI-S influences the secretion of gut hormones, adipocytokines, and incretins, which are pivotal in regulating appetite, insulin sensitivity, and glucose metabolism. These hormonal changes contribute significantly to the procedure’s metabolic benefits (35,36).

Surgical technique

The laparoscopic approach can be performed using either the American or French technique. The procedure begins with pneumoperitoneum creation. After inspecting the abdominal cavity, a vertical SG is performed. This involves complete devascularization of the stomach’s greater curvature, sealing the gastric branches of the gastroepiploic and short gastric vessels up to the left diaphragmatic crus. A bougie of 38 to 54 Fr is used for calibration, and the gastric resection is executed with an endoscopic stapler. Hemostasis is ensured selectively using hemostatic clips or monofilament sutures.

The first portion of the duodenum is mobilized posteriorly until the gastroduodenal artery is exposed, creating a window in the hepatoduodenal ligament while preserving the right gastric artery. The duodenum is transected at the level of the gastroduodenal artery using a linear stapler, ensuring a proximal duodenal stump of 3–4 cm and avoiding damage to the common bile duct (30).

After completing the SG and duodenal division, the patient is repositioned horizontally, and the surgeon moves to the patient’s left side. The ileocecal valve is identified, and 250–300 cm of the ileum is measured proximally (37). The intestinal loop is then cranially elevated in an antecolic manner to the duodenal stump, and an isoperistaltic, side-to-end duodeno-ileal anastomosis is performed. Finally, the excised stomach is removed.

A systematic review including 12 studies with 581 patients highlighted technical variability in SADI-S, particularly in the length of the common channel: 200 cm in 13.4% of cases, 250 cm in 23%, and 300 cm in 54.2% (38). Duodeno-ileal anastomosis was performed with manual suturing in 73.3% of cases and with a linear stapler in 26.7%. Although SADI-S involves a single anastomosis, the creation of a duodeno-ileal anastomosis requires advanced laparoscopic skills. As a result, the learning curve for SADI-S is considered intermediate to steep, typically requiring 30–50 procedures to achieve proficiency (39). The operative time for SADI-S typically ranges between 120 and 180 minutes, depending on the surgeon’s experience and the patient’s anatomy (40).

Results

SADI-S has been used as a staged procedure alongside SG to enhance effectiveness, particularly for class V obesity (BMI >60 kg/m²). The outcomes are promising, with reductions in obesity-related comorbidities and prevention of weight regain (Table 1).

Regarding weight loss, Spinos et al. reported a mean TBWL of 21.5–41.2% at 12 months post-SADI-S, with no weight regain observed after 24 months (41). Pereira et al. observed a BMI reduction from 48.6 to 28.2 kg/m² over 12 months and a peak %TWL of 41.6%, comparable to SG outcomes (36). According to the latest IFSO systematic review, primary SADI-S outcomes showed EWL ranging from 46.5% to 122% at 12 months, 67% to 114% at 2 years, and 100% at 3–4 years (32). TBWL reached 51% at 12 months and 57.1% at 3–4 years. For conversion cases, 12-month outcomes included 70% EWL and 25% TBWL, with improvements up to 80% EWL and 44.1% TBWL at 3–4 years (32). A systematic review found that SADI-S achieves higher %TBWL and %EWL at 1, 2, and 3 years than RYGB and OAGB (28). Additionally, SADI-S demonstrated superior diabetes resolution. However, early complications are more frequent with SADI-S, while late complications are more common with RYGB. Mortality rates remain low across all three procedures (28).

In terms of comorbidities, Sánchez-Pernaute et al. reported diabetes resolution with HbA1c levels decreasing to 5%, alongside remission rates of 73% for dyslipidemia, 58% for hypertension, and 88% for obstructive sleep apnea (42). Similarly, Spinos et al. observed complete resolution rates of 72.6% for T2DM, 77.2% for dyslipidemia, 59% for hypertension, and 54.8% for obstructive sleep apnea (41).

Complications

Early complications of SADI-S include leaks at the SG, duodeno-ileal anastomosis, or intestinal perforations, occurring in 1.3% of primary cases and up to 4% in conversion cases. Hemorrhages and hematomas are also significant concerns, with potential mortality if not promptly managed (32). Pennestrì et al. reported acute complications in 3.3% of cases, including pneumonia, hemorrhage, acute pancreatitis, and trocar site hernia, with the latter two requiring surgical intervention (40).

Late complications include hypoalbuminemia, with an incidence of 43.3% for a 250 cm common channel, decreasing to 7.1% with a 300 cm channel. Vitamin D deficiency was reported in 32% of cases, while anemia prevalence reached 24%, and trace element deficiencies (copper, zinc) affected up to 20% of patients. GERD development rates ranged from 0.6% to 35.3% (32). Initial studies suggest that SADI-S bypass may reduce the incidence of GERD compared to SG alone, due to decreased intragastric pressure and maintenance of partial pyloric function. Nevertheless, long-term data are still needed to confirm these findings (43).

SASI

The SASI is an emerging bariatric surgical technique that integrates principles of the OAGB and the SADI-S procedure described by Santoro. In 2016, Mahdy et al. modified Santoro’s transit bipartition by employing a single-loop reconstruction instead of a Roux-en-Y configuration (44). This adaptation resulted in the SASI procedure, which consists of an SG combined with a single, side-to-side gastroileal anastomosis.

Initial results from a study conducted by Mahdy et al. demonstrated an EWL of 75% at 6 months and 90% at 1 year postoperatively (44). Similarly, significant improvements in obesity-related comorbidities were observed, including complete diabetes remission within 3 months, hypertension resolution in 86% of cases, and improved lipid control. No perioperative mortality was reported. They hypothesized that the reduction in intestinal anastomoses decreases the risk of postoperative leaks, anastomotic strictures, and operative time. Additionally, an advantage of SASI is that it preserves duodenal continuity, allowing future endoscopic access to the duodenum and biliary system if required.

Mechanism of action

The weight loss and metabolic benefits of SASI are achieved through two primary mechanisms. The first involves gastric restriction from the SG. However, the primary focus of SASI lies in the second mechanism: neurohormonal modulation mediated by the gastroileal bypass.

GLP-1 is a key hormone secreted by L cells in the distal ileum and colon in response to nutrients, particularly glucose and lipids (45). GLP-1 exerts pleiotropic effects, including enhancing glucose-stimulated insulin secretion from pancreatic β-cells, reducing glucagon secretion from α-cells, improving insulin sensitivity, and promoting satiety through central nervous system pathways (45). These effects collectively support weight loss and glycemic control. A study by Zhang et al. demonstrated that plasma GLP-1 levels increased significantly more when glucose was infused into the distal small intestine compared to the proximal, highlighting the distal intestine’s superior role in modulating postprandial glucose metabolism (46).

Another critical hormone, peptide YY (PYY), is predominantly secreted in the distal gastrointestinal mucosa. PYY induces satiety by inhibiting orexigenic neurons and activating anorexigenic proopiomelanocortin (POMC)-producing neurons in the arcuate nucleus. One study observed that fasting PYY levels are lower in individuals with obesity and exhibit a blunted postprandial response, which improves with weight loss (47).

The gastroileal bypass component of SASI accelerates the delivery of chyme to the distal intestine, stimulating more effective secretion of GLP-1 and PYY. This hormonal modulation underpins the procedure’s impact on weight loss and comorbidity resolution (44).

Surgical technique

The technique described by Mahdy et al. is a laparoscopic approach performed in the French position with forced anti-Trendelenburg (44). The first 12 mm trocar is placed 20 cm below the xiphoid process and 3 cm to the left of the midline, with four additional ports positioned similarly to an SG. A standard SG is performed using a 36 Fr bougie for calibration. The surgeon then moves to the patient’s left side to identify the ileocecal junction, measuring 250 cm proximally to join the ileum to the anterior wall of the stomach antrum, 3 cm distal to the pylorus, using a linear stapler. The anastomosis diameter does not exceed 3 cm. The defect is closed in two layers, followed by a leak test using methylene blue (44). SASI bypass is considered to have an intermediate learning curve. Although the procedure combines a standard SG with a gastroileal anastomosis, achieving optimal limb measurement and secure anastomosis requires familiarity with both techniques. Proficiency is typically achieved after 20–30 cases (48).

Results

Since its inception, the SASI bypass procedure has demonstrated favorable outcomes in weight loss and remission of comorbidities. In 2020, Mahdy et al. reported results from a cohort of 605 patients (49). At 12 months post-SASI, there was a significant reduction in BMI, with a percentage of TBWL (%TBWL) of 27.4% and a %EWL of 63.9%. Complete remission of diabetes mellitus was achieved in 83.9% of cases, alongside remission rates for hypertension (36.1%), hyperlipidemia (65%), obstructive sleep apnea (57.8%), and GERD (92.1%). In 2021, Mahdy et al. compared three bariatric procedures: SG, OAGB, and SASI (50). At 6 and 12 months, SASI resulted in greater weight loss and BMI reduction, with superior %TBWL and %EWL compared to SG and OAGB (Table 1).

For comorbidities, diabetes mellitus remission was highest with SASI (97.7%), compared to SG (71.4%) and OAGB (86.7%) (50). Improvements in other comorbidities were similar across groups. In 2022, Tarnowski et al., in a single-center study, reported a mean %EWL of 88.3% at 12 months post-SASI, with 100% remission of diabetes mellitus and 80% remission of hypertension (51). In 2024, Parkitna et al. assessed SASI in terms of nutritional deficiencies, including iron metabolism disorders and anemia (52). The %EWL was 90.1%, and the %TBWL was 30.5%. Although a reduction in ferritin levels was observed, it was not statistically significant. De novo anemia occurred in 17.5% of patients. Among those with a 250 cm common channel, anemia was observed in 35.7%, compared to 27% in the 300 cm group, with no statistically significant difference.

Iron deficiency following SASI bypass may be less prevalent than with RYGB, as SASI bypass preserves passage through key iron absorption sites in the duodenum and jejunum. The common channel length may impact nutritional status, complication rates, and weight loss outcomes (52). The preservation of the pylorus in SADI-S minimizes the risk of GERD, providing a functional barrier against both acid and bile reflux. Nevertheless, isolated cases of bile reflux have been reported, particularly when sleeve calibration is excessively tight (53). Despite its metabolic benefits, SADI-S is associated with a non-negligible risk of nutritional deficiencies, including iron-deficiency anemia, hypoalbuminemia, and fat-soluble vitamin deficiencies, particularly in patients with shorter common channels. Lifelong supplementation and regular nutritional monitoring are essential (54). A common channel length between 250 and 350 cm is recommended, balancing adequate weight loss and minimizing complications such as protein-calorie malnutrition and iron metabolism disorders (52). In 2024, Abdelrahman et al. evaluated SASI in super-obese patients (BMI >50 kg/m²) with metabolic syndrome. The %EWL was 57% at 6 months and 83% at 12 months, with normalization of HbA1c and significant improvements in lipid profiles and blood pressure (55).

Complications

In 2020, Kermansaravi et al. reported two cases of conversion from SASI to SG due to weight loss associated with protein malnutrition (56). Mahdy et al. reported a 10% complication rate, mostly minor, including vomiting and diarrhea, managed conservatively (49). Major complications requiring surgical intervention included obstructive jaundice and staple line bleeding.

When comparing SASI with SG and OAGB, Mahdy et al. found that SASI had the highest short-term complication rate, although the differences were not statistically significant (50). At mid-term follow-up (up to 2 years), SASI has demonstrated sustained weight loss without significant weight regain; however, long-term studies are needed to confirm the durability of these results (57). For long-term complications, SASI showed the highest rate (14.9%) compared to OAGB (9.8%) and SG (2%). Hypoalbuminemia rates were similar between SASI and OAGB.

While SASI is effective for weight loss and obesity-related comorbidities, it is associated with higher rates of long-term nutritional complications, necessitating careful patient selection and close follow-up (48).

SG-TB

In 2003, Santoro et al. introduced the SG-TB, a procedure similar to BPD-DS but designed to preserve the pylorus and significantly minimize the malabsorptive component (58). Unlike BPD-DS, SG-TB retains the functional capacity of the duodenum and jejunum for nutrient absorption and neuroendocrine signaling. This approach mitigates nutritional complications while enhancing distal intestinal stimulation. Another notable advantage of SG-TB is the preserved endoscopic access to the duodenum and proximal intestine, which can be crucial for patients requiring subsequent diagnostic or therapeutic endoscopic interventions (58,59).

From a technical perspective, SG-TB avoids manipulation of the lesser gastric curvature, simplifying the anastomoses as they do not involve the duodenum or the upper stomach pouch (58). Some studies have demonstrated its safety and effectiveness in achieving weight loss and resolving obesity-related comorbidities (59-64).

In summary, the original design of SG-TB emphasizes adaptive and neuroendocrine mechanisms rather than relying solely on restriction or malabsorption (61). The absence of foreign devices or excluded segments, combined with full endoscopic access and ease of implementation, offers patients a corrective metabolic intervention well-suited for challenging dietary environments.

Mechanism of action

The SG-TB operates via two primary mechanisms. The first is a restrictive effect achieved through the SG. However, the procedure is primarily designed to capitalize on its second mechanism: stimulating the distal intestine by preferentially directing food transit to the ileum. A small portion of food continues to pass through the duodenum, reducing over-nutrition of the proximal intestine without eliminating it entirely. This design minimizes the adverse effects of malabsorption (59).

Nutrient absorption in the distal intestine triggers the secretion of GLP-1, which plays a pivotal role in metabolic regulation. The early and robust elevation of GLP-1 can delay gastric emptying, induce central satiety, promote beta-cell trophism in the pancreas, and enhance insulin secretion, leading to improved diabetes control (62). Additionally, satiety is further augmented by the secretion of PYY and oxyntomodulin.

Santoro’s initial results revealed a significant decrease in fasting ghrelin levels and improved secretion of PYY and GLP-1 across all patients following the procedure (58).

Surgical technique

The procedure combines a standard SG-TB via Roux-en-Y bypass, incorporating distinctive features. This approach creates a shortcut to the ileum while maintaining access to the duodenum.

Santoro’s original technique includes SG, omentectomy, and enterectomy, preserving the initial 40 cm of the jejunum and the terminal 260 cm of the ileum, ensuring sufficient intestinal length for adaptation. The jejunum is laterally anastomosed to the ileum 80 cm proximal to the cecum. A gastroileostomy establishes a transit bipartition, allowing both ileal and proximal intestinal transit (58).

In 2012, Santoro published a revised version of the technique (59). The laparoscopic approach begins with the creation of a pneumoperitoneum using a Veress needle. Six trocars are placed: three 12 mm trocars (one 3–5 cm above the umbilicus on the midline, and two in the left and right upper quadrants) and three 5 mm trocars (one in the epigastrium for liver retraction and two in each lateral flank). Omental division is performed, and the greater curvature is dissected from 2 cm proximal to the pylorus to the angle of His. If a hiatal hernia is present, a hiatoplasty is conducted. The SG begins 4–5 cm from the pylorus using a linear stapler, continuing up to 0.5 cm from the angle of His, calibrated with a 36 Fr bougie. The ileocecal valve is identified, and the ileum is measured 260 cm proximally, where enterotomies are created in the ileum and the gastric antrum. A 3–4 cm wide antecolic lateral-lateral gastroileal anastomosis is performed and closed with 3-0 absorbable sutures. The Roux-en-Y is completed with a lateral-lateral ileoileal anastomosis 80 cm from the ileocecal valve to create a common channel, using a 45 mm linear stapler (59). The SG-TB is a relatively new bariatric procedure. While its effectiveness and safety are increasingly documented, there is currently no direct research quantifying the learning curve for SG-TB that shows many cases a surgeon needs to perform to achieve proficiency.

Results

In 2012, Santoro et al. published 5-year outcomes of transit bipartition with SG in 1,020 obese patients (59). The mean percentage of excess BMI loss (%EBMIL) was 91%, 94%, 85%, 78%, and 74% in the first, second, third, fourth, and fifth years, respectively. Patients reported early satiety and significant improvement in comorbidities, including 86% complete remission of diabetes, 91% remission of sleep apnea, 85% improvement in dyslipidemia, and 72% remission of hypertension (59). In 2020, Topart et al. compared SG-TB with RYGB in patients with superobesity (BMI >50 kg/m²) (63). While SG-TB had a longer operative time, it resulted in greater weight loss at two years, with %EBMIL of 85.3% vs. 73.9% for RYGB. Both procedures demonstrated similar improvement in comorbidities. SG-TB appears relatively more effective for patients with superobesity.

In a 2021 case series by Calisir et al., 3-year outcomes demonstrated 84.3% diabetes remission, with a reduction in mean BMI from 44.7 to 29.7 kg/m² (64). The %TBWL was 33.84%, and the %EBMIL was 77.19%. No significant differences were observed in mean albumin, vitamin B12, or folate levels. In 2022, Al et al. analyzed 355 obese patients with T2D and a mean HbA1c of 9.8% (60). The mean operative time for SG-TB was 124±25.4 minutes, and the average hospital stay was 4.0±2.5 days. At 2 years, TBWL reached 20.2%, %EBMIL was 87.7%, and BMI decreased by 7.0 kg/m². HbA1c decreased by 3.5%±1.5%, with significant improvements regardless of diabetes duration. Similarly, at 2 years, 79% of patients achieved complete diabetes remission, 8.7% experienced partial improvement, and no patients required insulin. Of the 89% who initially required medication, only 15% continued using it postoperatively. Nutritional follow-up revealed significant improvements in vitamin D, calcium, and albumin levels. Preoperative deficiencies in vitamin D decreased from 26.8% to 0.3%, and calcium deficiency prevalence dropped from 17.7% to 2.4%. Iron deficiency and B12 deficiency were the most common postoperative complications, occurring in 12.4% of cases (60).

In 2023, Demir et al. compared transit bipartition with vertical SG against two modern techniques: OAGB and SG with loop bipartition (65). SASI required less operative time. Postoperative assessments showed significant reductions in HbA1c, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels across all groups, while OAGB was associated with lower postoperative vitamin D levels. Weight loss was significant across all procedures, with SASI achieving the highest %EBMIL (79.3%) compared to SG-TB (61.8%). In 2024, Widjaja et al. reported the use of single-port laparoscopy for SG-TB in a small cohort (66). The mean operative time was 150 minutes, with no conversions to multiport, no intraoperative complications, and no 30-day readmissions.

Complications

In 2012, Santoro et al. reported a 30-day complication rate of 3.7%, including fistula (0.9%), bleeding (0.8%), intestinal subocclusion (0.8%), non-obstructive ileus (0.7%), and atelectasis or pneumonia (0.5%) (59).

In 2022, Al et al. documented an overall complication rate of 10.2%, with no mortality (60). Early complications occurred in 8.6% of patients, including diarrhea (2.8%), intestinal subocclusion (1.7%), bleeding (1.4%), and symptomatic atelectasis (0.3%). Late complications (1.6%) included upper gastrointestinal bleeding, gastroileal anastomosis stricture, and marginal ulcers, all resolved with conservative management.

Strengths and limitations

This review provides a comprehensive and structured comparison of four innovative bariatric procedures: OAGB, SADI-S, SASI, and SG-TB. Focusing on their mechanisms, surgical techniques, outcomes, and complications. A key strength is the inclusion of recent data and emerging evidence, offering clinicians an updated reference for decision-making. The article also highlights neurohormonal mechanisms and metabolic effects beyond weight loss, often underrepresented in prior reviews. However, limitations include the heterogeneity of the included studies, with variations in surgical technique, follow-up duration, and patient selection criteria. Available evidence is largely derived from observational or retrospective studies, with a marked paucity of randomized controlled trials, particularly concerning the SASI and SG-TB techniques. Additionally, long-term data on nutritional deficiencies, quality of life, and weight regain are limited or inconsistent across procedures. These gaps highlight the need for more standardized, high-quality research to strengthen comparative conclusions.

Conclusions

The evolving landscape of bariatric surgery offers a variety of surgical techniques, each with distinct advantages tailored to different patient needs. The OAGB is appreciated for its simplicity, shorter operative time, and favorable weight loss outcomes, making it a strong option for super-obese patients. The SADI-S stands out for its effective weight loss, lower complication rates, and potential for metabolic improvement, particularly in patients with severe obesity and comorbidities. Finally, both the SASI and the SG-TB rely on neurohumoral and endocrine changes to provide adequate weight loss and metabolic control. While these techniques show considerable promise, more high-quality, long-term research is essential to establish clear guidelines for their optimal use. Comparative studies examining outcomes, complications, and quality of life are needed to better determine which approaches offer the most benefit for specific patient populations. As bariatric surgery continues to evolve, these findings will guide clinicians in providing tailored, evidence-based care. The future of bariatric surgery lies in refining these techniques, understanding their mechanisms more deeply, and continuously innovating to improve patient outcomes and quality of life.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-25-24/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-25-24/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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