**5. Advantages of sleeve-plus procedures**

Several advantages can be gained from sleeve-plus procedures. First, it allows the remaining stomach to be screened for gastric cancer, which is frequently done in areas of high gastric cancer prevalence such as Japan and Korea [23]. Screening will be difficult to do in RYGB.

In the techniques where anatomical and functional preservation of the pylorus is done, the gastric mucosa is protected against pancreatic and biliary fluids; hence, preventing bile acid gastritis [24]. The pylorus also regulates gastric emptying which results to a lower incidence of dumping syndrome [25]. The larger gastric mucosal contact to food in SG compared to that in RYGB also improves the absorption of iron, calcium, vitamin B12 and protein leading to less nutritional deficiencies [26].

Sleeve-plus procedures are quite versatile if a conversion to another procedure become warranted, whether due to weight regain, or complications of leaks and strictures. The loop SGDJB may be converted to a DS by transecting the afferent limb and anastomosing it to the distal segment of the efferent limb. The Roux-en-Y SGDJB can also be converted into DS by lengthening the alimentary limb from the biliopancreatic limb. Conversion to RYGB of any sleeve-plus procedure is also feasible. Index sleeve-plus procedures with a transected duodenum requires the proximal duodenal anastomosis to be taken down to allow resection of the distal gastric tube. The previous alimentary limb is then anastomosed to the remaining gastric pouch. In an SGPJB, a gastric pouch is simply created and anastomosed to the blind limb to construct the alimentary limb. In SG with bipartition, the gastroenteric anastomosis is transected, a gastric pouch is created, and a Roux-en-Y reconstruction of the bowel is done.

Loop techniques of sleeve-plus procedures have an additional advantage over the Roux-en-Y techniques. The single anastomosis in loop procedures allow for a shorter operative time and less potential complications that may arise from every additional anastomosis. The number of anastomoses also translates to the number of man-made hernial defects that necessitates closure. Another advantage of the loop techniques is that marginal ulcers have not been reported [20]. This may be due to the immediate neutralization of the gastric fluid by the bile juices once in the duodenum.
