International Journal of Surgery 34 (2016) 28e34

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International Journal of Surgery

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Original Research

Efficacy of single anastomosis sleeve ileal (SASI) bypass for type-2

diabetic morbid obese patients: Gastric bipartition, a novel metabolic
surgery procedure: A retrospective cohort study
T. Mahdy a, b, *, A. Al wahedi b, C. Schou b, c
a
Mansoura Faculty of Medicine, Mansoura, Egypt
b
Al Qassimi Hospital, Sharjah, United Arab Emirates
c
Aker University, Oslo, Norway

h i g h l i g h t s

(SASI) bypass is a Novel Metabolic/Bariatric Surgery operation based on mini gastric bypass operation and Santoro's operation, it is a therapeutic option
for obese T2DM patients.

SASI bypass is a promising operation, with very good results as DS operation without malabsorption morbidity. The elimination of two ways for passage
of food decrease nutritional deficiency.

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The single anastomosis sleeve ileal (SASI) bypass is a Novel Metabolic/Bariatric Surgery
Received 12 April 2016 operation based on mini gastric bypass operation and Santoro's operation in which a sleeve gastrectomy
Received in revised form is followed by a side to side gastro-ileal anastomosis. The purpose of this Study is to report the clinical
17 June 2016
results of the outcomes of SASI bypass as a therapeutic option for obese T2DM patients.
Accepted 12 August 2016
Available online 19 August 2016
Methods: We conducted a retrospective cohort study of type 2 diabetic obese patients who underwent
SASI bypass at one hospital from March 1, 2013 to December 31, 2014. Patients with previous bariatric
surgery, history of upper laparotomy, and with less than one year follow up, were excluded. Sleeve
Keywords:
SASI bypass
gastrectomy was performed over a 36-Fr bougie, 6 cm from the pylorus, and 250 cm from the ileocecal
Obesity valve the ileum brought to be anastomosis side to side with the antrum. Data collected included co-
Type 2 diabetes morbidity resolution, percent excess weight loss (% EWL), and one-year morbidity and mortality.
Digestive adaptation Results: During the study period, 61 underwent laparoscopic SASI bypass. Ultimately, 50 patients with a
mean BMI of 48.7 ± 7.6 kg/m2 met inclusion criteria and were evaluated. %EWL reached 90% at one year
and all patients have normal glucose level in the first 3 months after surgery. Hypertension remitted in
86%, hypercholesterolemia in 100% and hypertriglyceridemia in 97% of patients. There were 6 post-
operative complications. One pulmonary embolism, one postoperative bleeding, one leak from biliary
limb and one complete obstruction at the gastro-ileal anastomosis. Six months postoperative, one patient
was diagnosed with marginal ulcer, 12 months after surgery, another patient was re-operated for fear of
more excessive weight loss.
Conclusion: SASI bypass is a promising operation that offers excellent weight loss and diabetic resolution.
© 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Obesity and type 2 diabetes mellitus (T2DM) has become a

* Corresponding author. Prof. Tarek Mahdy, Mansoura Faculty of Medicine,
Mansoura, Egypt.
E-mail addresses: tmahdy@yahoo.com (T. Mahdy), abdulwahid66@hotmail.com
(A. Al wahedi), cfschou@online.no (C. Schou).
major public health problem [1], and medical treatment fails to
provide adequate control in a significant number of obese diabetics.
Bariatric surgery seems to be the most effective treatment for
T2DM in obese patients [2]. Mechanical obstacles to food ingestion,

http://dx.doi.org/10.1016/j.ijsu.2016.08.018
1743-9191/© 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
 T. Mahdy et al. / International Journal of Surgery 34 (2016) 28e34
nutrient-excluded segments and malabsorption are common stra-
tegies of bariatric surgery, which are a potential cause for compli-
cations and should be better avoided from a strictly physiological
point of view [3].
The digestive physiology is now changing and the interacting
neuroendocrine signals that control hunger, satiety, and energy
expenditure are understood now. The role of GI tract in satiety is a
sum of a mechanical sensation of a full stomach, rapidly confirmed
by neuroendocrine signals that recognize whether what was
ingested was indeed nutritive. In terms of meal termination, the
most important of these postprandial neuroendocrine signals are
an elevation in the blood of satiety gut hormones (such as GLP-1
and PYY) and a reduction of ghrelin, an orexigenic hormone
mainly produced by neuroendocrine cells mostly located in the
gastric fundus [4]. Recent physiological knowledge allows the
design of bariatric procedures that aim at neuroendocrine changes
instead of at mechanical restriction and malabsorption. Digestive
adaptation is a surgical technique for obesity based on this rationale
[5].
Santoro et al. have recently reported his long-term data
regarding sleeve gastrectomy with transit bipartition (SG þ TB),
which is a similar operation to duodenal switch (DS) but without
complete exclusion of duodenum in order to minimize nutritional
complications [6]. The goal of this operation was to benefit the
patients by counterbalancing the harmful effects of the modern
diet. Without exclusions and with a simple surgical procedure,
SG þ TB amplify the nutritive stimulation of the distal gut whereas
simultaneously diminishing the exposure of the proximal bowel to
nutrients without completely deactivating duodenum and
jejunum.
We modified the SG þ TB by performing a loop rather than
Roux-en-Y bipartition reconstruction in Santoro's operation and
The purpose of this study was to evaluate the efficacy and of SASI
bypass as a mode of functional restrictive and neuroendocrine
modulation therapeutic option for obese T2DM patients.
2. Materials and methods
2.1. Patients
We conducted a retrospective cohort study among morbid
obese patients with type2 diabetes (T2DM) treated with SASI
bypass (Fig. 1) between March 1, 2013 and December 31, 2014 in
Fig. 1. SASI bypass.
29
one hospital. Data collection began before the operation and
continued forward until the latest office visit after the operation.
The protocol of this study was approved by the hospitals' Institu-
tional Review Board and its Research Registry Unique Identifying
Number is researchregistry1155. All patients undergoing the sur-
gery were between 18 and 60 years of age. Patients who completed
at least one-year follow up were included in the study. Exclusion
criteria included patients with; 1) history previous bariatric sur-
gery, 2) history of upper laparotomy, and 3) history of psychological
instability.
2.2. Before the surgery
Informed consent was obtained from all patients after
describing the operative and postoperative details and complica-
tions. All patients had preoperative evaluation including careful
history taking, clinical examination, and laboratory investigation
including blood glucose, lipid profile, and thyroid and suprarenal
hormonal evaluation. Diagnosis of T2DM was based on Fasting
plasma glucose concentrations >126 mg/dl or those with positive
history and under antidiabetic medications. In addition, routine
gastroscopy was performed and abdominal ultrasound to exclude
gallstones and to evaluate the degree of fatty liver. The liver size
reduced by keeping all patients on a low-calorie protein diet for 6
weeks. Deep vein thrombosis prophylaxis started 12 h before sur-
gery with low molecular weight heparin subcutaneous injections.
2.3. Operative techniques
The operation was done under general anesthesia. The patient
was in French position. The first part of the operation is performed
on the operating table under forced anti-Trendelenburg position
and the surgeon positioned between the legs of the patient; The
procedure started using Excel 12-mm optical trocar (Ethicon, USA)
to enter the abdomen under direct vision about 20 cm below the
xiphoid process and 3 cm to the left side of the midline. Pneumo-
peritoneum was achieved with carbon dioxide at 15 mmHg. Four
additional ports were placed under direct vision, the same sites as
in sleeve gastrectomy. The technique commences with the devas-
cularization of the greater curvature of the stomach with the har-
monic scalpel (Ultracision, Ethicon Endo-Surgery, Inc., Johnson &
Johnson). The dissection then continued toward the gastroesoph-
ageal junction. The left cru was then completely freed of any at-
tachments to avoid leaving a posterior pouch when constructing
the sleeve in this region. Posterior attachments between the
stomach and pancreas were then divided. The stomach is then
tabularized over a 36 French calibration tube, with a linear stapler
(Echelon 60, Ethicon Endo-Surgery, Inc., Johnson & Johnson)
charged with a green cartridge, commencing 6 cm proximal to the
pylorus. We perform a running suture all over stapler line. When
finished, the table is changed to the horizontal position and the
surgeon moves to the left-hand side of the patient to perform the
second part of the operation. The ileocecal junction is identified and
250 cm is measured upwards. The selected loop is ascended a
without division of the greater omentum, and a stapled iso-
peristaltic side-to-side to the anterior wall of the antrum of the
stomach just 3 cm away from the pylorus with a linear stapler
(Echelon 45, Ethicon Endo-Surgery, Inc., Johnson & Johnson)
charged with a green cartridge, the diameter of ileal antrum
anastomosis is not exceeding 3 cm in diameter. The staple defect is
closed with a two-layer running 3/0 polydioxanone suture (PDS
IITM, Ethicon, Inc., Johnson & Johnson). The transected stomach
was then removed through the 12-mm left midclavicular port. The
anastomosis is tested for water tightness with methylene blue test.
30 T. Mahdy et al. / International Journal of Surgery 34 (2016) 28e34
2.4. After surgery
Ambulation and clear liquids were started on the night of the
operative day. Thrombosis prophylaxis (enoxaparin 40 once daily)
continued from the first postoperative day up to 4 weeks. Before
discharge, gastrografin swallow X-ray study was routinely per-
formed between the second and third postoperative day (Fig. 2), to
exclude the leak. Proton pump inhibitor was administrated for 4
months postoperatively. Patients are reviewed as outpatients 2
weeks postoperatively then every month. Patients were also seen at
the outpatient clinic if they developed symptoms between their
follow-up visits. A low-caloric protein-rich liquid diet is maintained
over the first month and then other elements are sequentially
introduced under strict dietitian supervision, multivitamin and
vitamin D3 is systematically prescribed. Patients are encouraged to
initiate physical activity from the first postoperative week. All pa-
tients had a complete blood investigation every 3 months, and,
gastroscopy every 6 months. The patients were requested to state
their current medication, including multivitamin use.
2.5. Assessments
The primary outcomes were the percent of excess weight loss (%
EWL), resolution of diabetes and improvement of comorbidity. The
percent of EWL was calculated as follows: (preoperative weight
follow up weight)/preoperative excess weight  100. Resolution of
diabetes was defined in this study as a fasting plasma glucose level
<110 mg/dL or HbA1C level <6% without hypoglycemic medication
at 1 year after surgery. Whereas improvement was defined as a
reduction of at least 25% in the fasting plasma glucose level and of
at least 1% in the hemoglobinA1c level with hypoglycemic drug
treatment. Resolution of comorbidity was considered if the disease
is controlled without any medications.
Secondary outcomes were postoperative complications and
postoperative nutritional status.
2.6. Data collected
Preoperative data included age, gender, initial weight, initial
body mass index (BMI), excess body weight, obesity comorbidities
and treatment medications used (chest problems, diabetes, arterial
hypertension and cardiac ischemia, hyperlipidemia, obstructive
Fig. 2. Gastrografin study after SASI bypass.
sleep apnea syndrome (OSAS) using STOP-Bang score [7], gall-
stones, urinary stress incontinence, joint pain, depression, infer-
tility and heartburn). Operative data included operating time,
intraoperative complications (bleeding, splenic injury, esophageal
injury, liver tears and specimen retrieval problems) and stapler
malfunction. Postoperative data included % excess weight loss, BMI,
hospital stay, early postoperative complications during the first
month (e.g. fever, collection, bleeding, vomiting, leak and port site
problems. Long-term complications more than 1 month after sur-
gery as vomiting, reflux, stricture, intestinal obstruction, hypo-
albuminemia, anemia and calcium or iron or vitamin D or vitamin
B12 deficiency were collected.
2.7. Statistical analysis
Data were analyzed using IBM® SPSS® (version 21.0 for Win-
dows). Unless stated otherwise, all data are expressed as the
mean ± standard deviation (SD) or as percentages. Descriptive and
inferential statistical analyzes were performed using both para-
metric and nonparametric procedures as appropriate. Comparisons
of categorical/ordinal variables were performed using chi-square
analysis for trends. Continuous variables were compared using an
independent group test. All tests were two-tailed, and the results
with p < 0.05 were considered statistically significant.
3. Results
During the study period, 67 patients underwent SASI bypass and
completed one-year of follow up. Seventeen patients were
excluded from the study, including 13 patients with history of
previous bariatric surgery (7 gastric banding and 6 sleeve gastrec-
tomy), 3 patients with history of upper laparotomy and one pa-
tients with history of psychological instability. Ultimately, 50
patients were evaluated, 33 women, and 17 men, with a mean BMI
of 48.7 ± 7.6 kg/m2, mean age 40.5 ± 7.9 years. The mean operative
time was 114 ± 30.5 min, and the mean postoperative hospital stay
was 2.9 ± 1.7 days. Percentage Excess weight loss (calculated from
an ideal BMI of 25 kg/m2) has been excellent; there were 75% at 6
months, 90% at a first year. The mean diabetes disease duration was
8.6 ± 7.9 years. The mean preoperative fasting blood glucose was
169.2 ± 74.2 mg/dL, and the mean glycated hemoglobin (HbA1c)
was 9.9% ± 2.7%. Preoperatively, 10 patients required insulin and
 T. Mahdy et al. / International Journal of Surgery 34 (2016) 28e34
oral hypoglycemic drugs to control diabetes and the rest of patients
have control with oral hypoglycemic drugs. The mean preoperative
C-peptide level was 2.12-±1.2 ng/m.
Hypertriglyceridemia was detected in 35 patients; hypercho-
lesterolemia was detected in 25 patients, obstructive sleep apnea in
five patients, and hypertension in 15 patients.
3.1. Primary outcomes
Percentage excess weight loss (calculated from an ideal BMI of
25 kg/m2) has been excellent; there were 75% at 6 months, 90% at a
first year. All patients have complete resolution of diabetes in the
first month postoperatively except five patients had resolution after
3 months and required the gradual withdrawal of insulin and hy-
poglycemic drugs. Those patients had longstanding (>10 yr) severe
T2DM and under treatment of oral hypoglycemic and insulin
treatment. Hypertension remitted in 86% (13 patients) of the cases
and the other two patients are still under anti-hypertensive treat-
ment though both dosage and number of drugs have been reduced.
Hypercholesterolemia improved in all cases, with absolute
normalization of all parameters, Hypertriglyceridemia improved
significantly in 97% (34 patients) of cases. Glycemic and lipid profile
pre and postoperative mean values listed in Table 1.
3.2. Secondary outcomes
No intra-operative complications and no postoperative deaths
were registered. There were six postoperative complications. One
pulmonary embolism responded to conservative treatment. One
postoperative bleeding from the staple line of the stomach, which
required laparoscopic exploration 12 h postoperatively and
controlled by suturing of bleeding points at the stapler line. There
was one leak from the biliary limb of the ileum most probably by
traumatic injury from non-traumatic grasper, which was treated by
laparoscopic exploration and simple suturing at the first post-
operative day. One patient diagnosed as a complete obstruction at
the gastro-ileal anastomosis in the second postoperative day, which
was treated by urgent laparoscopic exploration, and refashioning of
the gastro-ileal anastomosis. Six months postoperatively, one pa-
tient diagnosed by gastroscopy had a marginal ulcer, which
responded easily to medical treatment, this patient discontinued
anti-ulcer drug after discharge from the hospital and he is a heavy
smoker. Twelve months after surgery, one patient re-operated for
fear of more excessive weight loss (without nausea and vomiting)
and reverse back to the normal anatomy, 4 months later; he
reached a BMI above 24 kg/m2 and developed impaired glucose
tolerance. Up till now, none of the patients' studies diagnosed, by
endoscopy or biopsy, to have biliary gastritis. The mean number of
daily bowel motions was 1.5 ± 1.9 with only two patients reporting
3 times. Mean values of serum biochemical profiles pre and post-
operatively listed in Table 2.
Postoperatively, the mean total protein concentration was
Table 1
Glycemic and lipid profile pre and postoperative mean values.
Preoperative 3 month postoperative
FBS mg/dl 169.2 ± 74.2 109.5 ± 11.8
HbA1c (%) 9.9% ± 2.7% 6.1% ± 0.7%
C-peptide ng/ml 2.1 ± 1.2 1.8 ± 1.1
Triglycerides mmol/L 2.7 ± 0.7 1.4 ± 0.6
Cholesterol mmol/L 6.9 ± 1.8 4.6 ± 0.9
HDL mmol/L 1.2 ± 0.9 2.3 ± 0.8
LDL mmol/L 4.9 ± 1.9 2.5 ± 0.8
❖Significant p value < 0.05.
31
7.8 ± 1.1and mean albumin concentration was 3.9 ± 0.9 g/dl. One
patient had mild hypoalbuminemia but more than 3 g/dl due to
food rejection (without a mechanical reason) in fear of weight
regain and responded well to conservative treatment. It is impor-
tant to highlight that all of our patients (100%) preoperatively, had
vitamin D deficiency and received oral reinforcement with high
vitamin doses before surgery, after surgery all patients had normal
serum vitamin D with 1000 IU daily supplementation. Blood anal-
ysis was performed every 3 months after surgery; the mean he-
moglobin value was 12.4 ± 1.4 g/dl, hematocrit, 40.5% ± 10.6 and
iron, 22-±11.8 mg/dl. It is important to know that 12 patients had
iron deficiency anemia and corrected before operations. Nutritional
values before and after SASI bypass listed in Table 3.
4. Discussion
This study is reporting the first clinical results of the efficacy of
SASI bypass. The results have demonstrated that SASI bypass is a
safe and effective procedure in type 2 diabetes obese patients.
Nowadays the modern human diet became hyper-caloric, poor
in fiber, predigested by cooking and refining and extremely easy to
be absorbed. By this manner of diet, the product is completely
ready for absorption, such as glucose. Absorption may occur in
more proximal portions of the bowel, reaching peaks of nutrient
absorption. The distal bowel may have less absorption work,
causing a lack of production of GLP-1 and PYY. As a result, it was
noticed that the diabetic and the obese patients have a reduced
production of GLP-1 [8e10].
Most of the bariatric operations to counterbalance obesity take
its toll on the human health. Some treatments induce nonspecific
malabsorption, therefore leading to loss of non-caloric nutrients
like calcium, iron, folic acid, etc. Some procedures hinder food
ingestion, through the use of narrowing anastomoses or sometimes
the use of prostheses [11]. These develop dysphagia, vomiting,
stasis esophagitis, etc. Whereas other procedures involve digestive
tract exclusions that cause atrophy of the mucosa, with bacterial
proliferation that leads to bacterial translocation to the portal
system which associated with hepatic decompensation [12] that
may worsen the hepatic condition of patients that frequently pre-
sent with some degree of nonalcoholic fatty liver disease [13]. Even
in gastric bypass operation, hepatic insufficiency may happen [14].
Moreover, failure of endoscopic exploration of the duodenum and
the biliary system is another drawback of these procedures.
The ideal procedure should modulate the neuroendocrine con-
trol of hunger and satiety and should not cause harm to important
digestive functions unrelated to obesity, like the gastric, pyloric and
duodenal functions. Digestive adaptation is a surgical technique for
obesity based on this rationale. Santoro et al. designed sleeve gas-
trectomy with transit bipartition to work primarily through func-
tion restriction and neuroendocrine modulation, avoiding
mechanical restriction and malabsorption, which have formed the
cornerstones of bariatric surgery until recently [15].
6 month postoperative 12month postoperative P Value
101 ± 9.8 85 ± 11.8 0.001
5.7 ± 0.8% 5.1 ± 0.8% 0.001
1.9 ± 1.4 2.1 ± 1.9 0.066
1.1 ± 0.9 1.2 ± 0.8 0.021
3.9 ± 1.2 3.1 ± 1.1 0.001
2.5 ± 1.9 2.9 ± 1.2 0.001
2.2 ± 0.9 2.1 ± 0.8 0.001
32 T. Mahdy et al. / International Journal of Surgery 34 (2016) 28e34

Table 2
Mean values Serum biochemical profiles pre and postoperative.

Preoperative 3 month postoperative 6 month postoperative 12month postoperative P Value

Sodium mmol/L 140.4 ± 9.7 143.2 ± 8.4 141.5 ± 9.73 144.1 ± 6.5 0.055
Potassium mmol/L 3.7 ± 1.4 3.8 ± 1.5 4. ±0.9 4.2 ± 0.7 0.052
Phosphorus mmol/L 0.9 ± 0.4 0.8 ± 0.6 0.9 ± 0.7 1.1 ± 0.9 0.066
Calcium mmol/L 2.2 ± 0.7 2.4 ± 0.9 2.3 ± 0.3 2.3 ± 0.5 0.069
Urea mmol/L 6.1 ± 3.2 7.2 ± 4.5 8.1 ± 2.7 6.9 ± 3.9 0.077
Creatinine mmol/L 83 ± 10.7 88 ± 11.4 74 ± 9.1 75 ± 8.9 0.065
Bicarbonate mmol/L 26.9 ± 7.7 24.2 ± 8.6 23.2 ± 5.3 23.6 ± 6.7 0.054
ALT IU/L 88 ± 22.7 50 ± 11.5 33 ± 12.9 34 ± 0.7 0.001
Gamma-GT IU/L 33 ± 12.3 25 ± 11.7 24 ± 10.4 22 ± 18.9 0.011

❖Significant p value < 0.05.

Table 3
Nutritional values before and after SASI bypass.

Preoperative 3 months postoperative 6 months postoperative 12 months postoperative P Value

Iron umol/L 14 ± 13.9 22 ± 11.8 23 ± 11.2 24 ± 12.9 0.001

Transferrin mg/dl 370 ± 30.3 210 ± 27.4 240 ± 29.6 220 ± 33.9 0.001
Ferritin mcg/L 20 ± 10.3 40 ± 29.6 44 ± 29.7 43 ± 20.9 0.006
Vitamin B12 pmol/L 329 ± 90.3 348 ± 80.9 360 ± 98.6 344 ± 96.4 0.064
Folic acid nmol/L 12.4 ± 0.7 12.6 ± 0.5 13.8 ± 0.9 13.1 ± 0.6 0.072
Vitamin D nmol/L 11 ± 9.2 40 ± 8.7 50 ± 9.1 53 ± 8.6 0.001
Albumin (g/dL) 3.8 ± 0.7 3.9 ± 0.9 4.3 ± 0.4 4.1 ± 0.9 0.082
Protein (g/dL) 7.9 ± 1.4 7.8 ± 1.1 8.1 ± 1.7 7.9 ± 0.7 0.074
Hemoglobin gm/dL 11.1 ± 1.7 12.4 ± 1.4 12.9 ± 1.6 12.8 ± 0.9 0.054
WBC count 4.5 ± 2.7 6.8 ± 1.1 6.1 ± 1.5 6.6 ± 1.9 0.65
10(3)/mcl
Platelets count 255 ± 21.8 298 ± 32.2 320 ± 30.3 310 ± 24.7 0.53
10(3)/mcl

❖Significant p value < 0.05.

The sleeve gastrectomy maintains gastric functions as the gen-
eral structure of the organ is preserved. During meals, distension
signals will be released earlier in a better accordance to the high
caloric density of modern food. During the period of fasting, less
Ghrelin is secreted because this orexigenic hormone is mostly
produced by cells located in the gastric fundus [16], which is sur-
gically removed. Sleeve gastrectomy is different from the gastric
banding that it works 24 h a day. The gastro-ileal bypass does not
aim to cause malabsorption. The rationale of this bypass is to the
rapid entrance of undigested Chyme into the distal intestine,
causing a more effective secretion of GLP-1 and PYY. These hor-
mones reduce the rate of gastric emptying (making the stomach
functionally even smaller), improve insulin secretion, and promote
central satiety [17e19].
SASI Bypass is a novel bariatric operation based on the principles
of sleeve gastrectomy with transit bipartition (SG þ TB). The reason
for modifying SG þ TB was to simplify the procedure and to
decrease the potential complication rate. Reducing the number of
intestinal anastomoses will be associated with less probability of
postoperative leaks, anastomotic strictures and operative time.
Moreover, the mesentery is not opened; there should be a lower
probability of postoperative obstructions.
The idea of weight loss after SASI bypass is neither because the
patient cannot eat what he wants nor cannot absorb nutrients
completely. But patients stop eating earlier because they have the
feeling that the stomach is full, and due to a hypothalamic-
generated satiety sensation, which is caused by the perception of
nutrients in their distal bowel. The intense distal gut stimulation
reduces proximal bowel activity in another important way, and
because distal gut hormones are satietogenic, they reduce gastric
emptying [20]. SASI Bypass strongly reduces meal size and over-
eating and leads to an important reduction in animal fat con-
sumption by changing taste preferences [21].
An adequate initial weight loss was predicted; because the
function restrictive component of the operation was, a sleeve gas-
trectomy and the gastro-ileal bypass induce neuroendocrine
modulation. Thus, in terms of weight loss and co-morbidities res-
olution, SASI bypass initially provides satisfactory results. The
weight loss was excellent from the beginning. The percentage of
excess weight loss (% EWL) was 75% by the first 6 postoperative
months and had reached a mean value of 90% at 12 months post-
operatively. These data were maintained during the whole follow-
up period and were significantly greater than those obtained with
other bariatric procedures [22,23]. Previous versions of the BPD and
the DS [24] have achieved a long-term (10 y) % EWL of 70e80%. In
the follow-up study by Hess et al. [25], a maximum weight loss was
obtained by the third postoperative year and then patients regained
minimally and to plateau around 75% EWL in the long term. In
contrary, our patients reached a greater peak earlier that could have
been attributed to the greater gastric function restriction.
Bariatric operations have demonstrated to be an effective
method to treat T2DM [26]. All successful operations significantly
improve insulin resistance and diabetes, but those based on mal-
absorptive principles get higher resolution rates [27]. SASI Bypass
comprises all the possible mechanisms involved in diabetes
improvement, which are a function restriction responsible of
reduction in the caloric intake, a rapid entrance of undigested
chyme into the distal intestine which amplifies the nutritive
stimulation of the distal gut and at the same time a smaller part of
the meal empties through the duodenum, diminishing the nutritive
overstimulation of the proximal gut but not reducing it completely,
and in the short run, maintained weight loss. In this way it is easily
explained why all diabetic patients in this study have completely
resolved their condition after the 3 months postoperative and with
no need of specific therapy or diet, they are able to maintain normal
levels of glycosylated hemoglobin.
 T. Mahdy et al. / International Journal of Surgery 34 (2016) 28e34
The modification was devised to simplify previous successful
Santoro's operation, keeping the digestive adaptation principles but
attempting to decrease the rate of surgical complications. There
were no intraoperative complications. One postoperative bleeding
from the staple line of the stomach. We protect the staple line with
running suture and currently we cover it with hemostatic sponges
to avoid bleeding. No leaks have been detected in the gastroeileal
anastomosis. One patient has been submitted to a reversal opera-
tion for fear of more excessive weight loss without nausea and
vomiting or malnutrition. Follow-up of our patients is still short,
most of the revisions of malabsorptive surgery for malnutrition are
performed between the first and the second postoperative year
[28]. None of our patients developed diarrhea and, taking into ac-
count that intestinal adaptation occurs, it is less probable that they
will develop it later. Furthermore, some of our patients developed a
slight diminution in the frequency of evacuations of stools, prob-
ably because they eat less, absorb food adequately, and the higher
levels of GLP-1 and PYY induce a slower intestinal transit and
gastric emptying [29,30].
The expected rate of an internal hernia after a Roux-en-Y pro-
cedure is variable, from 1% to 16% [31], and it should be reduced to
almost nil after loop reconstruction [32]. The average time to detect
postoperative internal hernia is 12 months, with almost 80% of
patients presenting before 20 months postoperatively [33]. In our
series, although we have not yet a single case of an internal hernia,
our patients have not long enough follow-up periods.
Unlike in a BPD, there is less liability to hypoalbuminemia, and
malabsorption is not a problem following SASI Bypass due to the
elimination of two ways to passage of foods. It is difficult to eval-
uate malnutrition when the patient is submitted to a “programmed
undernutrition” [34]. As a single value hardly reflects the exact
nutritional state, several markers are generally evaluated, including
blood cells and different protein levels. As expected, none of our
patients developed any signs of nutritional deficiency except Low
levels of albumin were detected in one case, this patient had very
low protein intake due to fear of weight regain. He was treated with
psychological support plus a protein-rich diet. The rates of
malnutrition are found after BPD or DS and gastric bypass is high,
and in most cases are secondary to non-compliance with the pre-
scribed diet, which must include a minimal intake of 90 g of protein
per day [35].
No alterations in blood cell counts or hemoglobin and iron levels
were detected post-operatively.
After BPD, the estimated prevalence of anemia is around 40%,
which can be reduced to 5% with proper iron and folate adminis-
tration [36]. Practically all our patients required calcium and
vitamin D3 supplements at short eterm postoperatively because all
of them had very low vitamin D preoperatively. High doses of
cholecalciferol are recommended for gastric bypass and for BPD
[37] to maintain normal levels of parathormone. Also, we detected
no alterations in vitamins or minerals postoperatively.
The quality of life seems to be much improved by the loss of
weight and resolution of diabetes. As well as, the absence of any
dysphagia, vomiting, diarrhea, and flatulence, need for life-long
pills those are associated with traditional procedures. SASI bypass
avoids all of these complaints except early satiety.
The most important issue, however, is that SASI bypass is highly
effective in treating both obesity and metabolic syndrome,
mimicking the results of a BPD while avoiding exclusions and
functional losses, diminishing nutritional damage, and remaining a
less complex operation. The elimination of two ways for passage of
food and one anastomosis decrease nutritional deficiency and the
possibility of surgically related complications. Although most pro-
cedures reduce endoscopic access, patients undergoing SASI Bypass
have a good access to the duodenum and biliary system. SASI
33
Bypass is simpler than sleeve SG þ TB because it has one anasto-
mosis and without mesenteric defect.
Limitations of this study include the small number of patients,
lack of a control group and short follow-up period. The data in the
present study remains preliminary and feasibility of this surgical
procedure on a large scale requires a lot of hard work.
More patients, longer follow-up, and multicenter experience are
all necessary to accurately figure out this procedure as a physio-
logical surgical intervention able to attenuate the metabolic dam-
age that modern food and new habits have caused in the last
decades.
5. Conclusion
SASI bypass is a promising operation, based on digestive adap-
tation physiologic principles, easier to perform than the Santoro's
operation and BPD modifications, and with very good results as
duodenal switch operation in the short run without malabsorption
morbidity. The absence of prostheses or excluded segments, full
endoscopic access, and easy feasibility associated with an excellent
weight loss and diabetic resolution. Confirmation of these data and
longer follow-up would strengthen the case for the consideration of
SASI Bypass as the most appropriate metabolic surgery procedure.
Compliance with ethical standards
All procedures performed in studies involving human partici-
pants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable
ethical standards.
Informed consent
Written informed consent was obtained from all patients
included in the study after detailed explanation of the SASI bypass
operation.
Ethical approval
The protocol of this study was approved by the hospitals'
Institutional Review Board and its Research Registry Unique Iden-
tifying Number is researchregistry1155.
Sources of funding
There was no financial support received.
Author contribution
Both the authors contributed to the study design, data collec-
tions, data analysis, writing, operation procedures and approved
the final version of the manuscript to be published.
Conflict of interest
There was no financial support received and all authors declared
that there is no conflict of interest related to this article.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.ijsu.2016.08.018.
34 T. Mahdy et al. / International Journal of Surgery 34 (2016) 28e34

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