Beyond the Procedure: Revisiting the Technical Determinants of Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

Metabolic and bariatric surgery has become an increasingly technique-sensitive field in which even modest intraoperative variations may influence postoperative physiology and long-term outcomes. Although sleeve gastrectomy and Roux-en-Y gastric bypass are well-established procedures, substantial heterogeneity persists in how key technical steps are performed. This review revisits several high-impact technical determinants that remain clinically relevant in routine practice, focusing on antral preservation and bougie calibration in sleeve gastrectomy, and pouch size and gastrojejunostomy (GJ) stoma diameter in Roux-en-Y gastric bypass. In sleeve gastrectomy, more aggressive antral resection and smaller bougie calibers may confer a modest short-term weight-loss advantage, but these benefits appear to be offset by trade-offs involving reflux, stricture, and postoperative intolerance. In Roux-en-Y gastric bypass, smaller gastric pouches and avoidance of an excessively wide GJ are generally associated with more favorable weight-loss outcomes, although reproducibility of construction may be more important than any single numeric target. Overall, current evidence does not support one universally ideal technical configuration. Rather, it supports a balanced strategy based on standardized, reproducible baseline technique, avoidance of extremes, and selective personalization according to patient phenotype, risk profile, and treatment goals.