We read with great interest the article on distalisation of standard Roux-en-Y gastric bypass by Navez et al. [1]. We congratulate them for the display and excellent results.

It is estimated that around 1% of patients with morbid obesity undergo bariatric surgery. These procedures have always been under scrutiny especially if the weight loss after the surgery does not meet the expectations [2].

A lot of surgical modifications have been advocated by bariatric teams to enhance the weight loss or improve the surgical outcome. Many authors have recommended revisional procedures including adjusting the limb length. Ghiassi et al. suggested better results with weight loss and resolution of co-morbidities with total alimentary limb length (TALL) of 400–450 cm [3].

A study suggested better outcomes with modifying the Roux-en-Y gastric bypass (RYGB) to a more distal bypass and having TALL of 400 cm. They concluded with better post-operative outcomes, less incidence of nutritional deficiencies [4].

Limb distalization (LD) is believed to be associated with nutritional deficiencies. However, a study by Shin et al. [5] showed incidence of 13.6% patients with nutritional deficiencies but suggested overall acceptable results with LD.

We agree that management of weight regain is a challenge in all bariatric units as the causes are usually multifactorial. Long-term results of any bariatric procedure will be the ultimate measure.

We would like to share our experience with 13 patients we have performed distalization of the standard Roux-en-Y gastric bypass due to weight regain years following the procedure.

All these patients in our hands required exploration of the pouch and the gastro-jejunal anastomosis. Most of them needed refashioning and the minority required only plication of the pouch over 34 F Bougie.

Our approach was to keep 3 meters of the common limb, leave the roux limb length as it was from the first surgery and, basically, increase the length of the biliopancreatic limb with the remaining small bowel.

This will provide the needed restriction, augment the hormonal and hypo absorption desired function of the biliopancreatic limb. In this series, we did not encounter malnutrition.

We believe that our technique is easy, just to transect the roux limb proximal to the previous jejunojejunostomy and create a new jejunojejunostomy between the roux limb and the ileum 3 meters proximal to the ileocecal valve.

We consider our results are comparable to the result indicated in the article and patients were satisfied with the overall outcome.