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All procedures were performed by the same surgical team. Pneumoperitonum created by direct puncture ( Veress needle technique). Four trocars are normally used. The first step consists of locating the ileocecal valve and measuring the jejunal loop for ∼300 cm. The patient is then placed in a 30° anti-Trendelenburg position. The angle of His is identified and the fat pad at the esophago-gastric (EG) junction explicitly dissected in order to visualize the diaphragm’s left crus for optimal endostapler positioning at this critical location. With associated lap band, this step includes section of lap band and its removal. Ultrasound shears are used to section the lesser gastric curvature’s fat and blood vessels at the level of the crow’s foot to enter the lesser sac. An endoscopic stapler loaded with a 60-mm/3.5-mm cartridge is inserted through the created opening and applied, sectioning the stomach horizontally. A orogastric tube is inserted to calibrate the gastric reservoir. Fatty tissue and fibrous adhesions between the posterior gastric wall and pancreas are dissected. Then, an endoscopic stapler loaded with 60- mm/3.5-mm cartridges is consecutively applied (usually five times), sectioning the stomach vertically and completing the gastric reservoir.
The latter should be long, narrow, well vascularized, and easy to move caudally. The orogastric tube is removed and the previously chosen SB mobilized upward placing it without tension in an antecolic, retrogastric position. A uncontinuous reabsorbable no. 2-0 suture is sewn in a latero-lateral position, securing the SB loop to the gastric reservoir’s staple line along ∼2–4 cm. Enterotomy and gastrotomy (distal reservoir) are done with monopolar hook. An endoscopic stapler loaded with a 35-mm/3.5- mm cartridge is partially inserted (∼75 %) and applied between both, thus creating a gastroenteric anastomosis ∼2–2.5 cm long. Incisions on the anterior anastomotic wall are sutured with reabsorbable no. 2-0 interrupted stitches and continuos suture with v-Loc. These measures unload anastomotic tension, improve its orientation, and reinforce the antireflux mechanism. Anastomosis integrity is verified with a idropneumatic test. The greater omentum is tucked and adhered to them. Lastly, a drain is positioned under the left hepatic lobe and brought out through the right subcostal incision.