Background

Robotic SADI-S is a safe and feasible metabolic and bariatric procedure that is ideal for patients with type 2 diabetes and BMI over 50 with no signfiicant GERD. We present the case of a 46 y/o female with severe obesity and BMI of 57, with type 2 diabetes, metabolic syndrome and mild GERD. She had a history of significant peptic ulcer disease (PUD) with H pylori infection requiring triple therapy and documentation of eradication. The patient was advised against a Roux en Y gastric bypass due to the need for possible endoscopic surveillance.She chose a robotic SADI-S, which was attempted but had to be converted to a robotic BPD due to inability to preserve the duodenal bulb due to severe PUD found intraoperatively . This finding required an en-bloc resection of the inflamed duodenal bulb and pylorus with conversion to BPD and sleeve gastrectomy in a Roux en Y configuration to avoid a loop anatomy that could promote bile reflux in the future. The procedure was performed successfully and the patient was discharged to home without complications.PUD and chronic duodenal bulb inflammation may be a contraindication for SADI-S or BPD-DS and may require conversion to BPD. A Roux en Y gastric bypass is relatively contraindicated in this context due to the possible need for endoscopic surveillance. The robotic platform offers several ergonomic advantages, but there is no substitute for good surgical judgment, which takes precedence over the MIS approach.