Bile aspiration during emergent revision of a single-anastomosis gastric (SASI) bypass to a Roux-en-Y configuration with transit bipartition: a case report

Single anastomosis sleeve ileal (SASI) bypass is an emerging bariatric procedure; some patients face complications such as severe bile reflux, requiring conversion. In this context, the surgical goal is to substantially reduce exposure of the stomach and gastroesophageal junction to bile acids to prevent early complications. We present a 46-year-old man with class III obesity (body mass index 54.6 kg/m²) who 10 days after an uneventful SASI bypass, developed intense, persistent, refractory reflux. A diagnostic endoscopy revealed an extensive accumulation of biliary reflux in the gastric lumen, prompting reintervention. During anesthetic induction, the patient aspirated bile, causing acute respiratory distress. After intraoperative stabilization, the team proceeded without further incident, converting the single-loop configuration to a Roux-en-Y transit bipartition, resolving gastroesophageal reflux disease (GERD). This case underscores the need to incorporate prevention maneuvers during anesthetic induction in patients with severe GERD to avoid aspiration, and the importance of anticipating high anesthetic risk in these individuals.