Comment on: The impact of routine division of the greater omentum on small bowel obstruction after Roux-en-Y gastric bypass

Roux-en-Y gastric bypass (RYGB) is the only bariatric surgery (BS) operation that can be said to have withstood the test of time. It was developed in 1977 by Griffen et al [ ]. elaborating on the bypass proposed by Mason [ ]; 45 years later, it is still stably the second most performed operation worldwide, representing around 30% of BS procedures (according to the latest International Federation for the Surgery of Obesity and Metabolic Disorders [IFSO] survey), and remains the procedure of choice for patients with concomitant severe gastroesophageal reflux or Barrett esophagus [ ]. Thus, despite evolution of and ferment around new BS procedures, RYGB remains the real gold standard and will probably remain so for years to come. Nonetheless, RYGB still has limitations that bariatric surgeons worldwide are trying to overcome. One of the major problems with RYGB is a relatively high long-term complication rate. In particular, small bowel obstruction (SBO) is a great contributor to this complication rate, with as many as 15% suffering from SBO at 5 years [ ]. In fact, the modifications in anatomy brought about by RYGB determine the existence of 2 mesenteric breaches that represent potential herniation sites: (1) Petersen’s space (between the anastomotic small bowel mesentery and the transverse mesocolon) and (2) the mesenteric breach below the entero-enterostomy. Furthermore, weight loss itself seems to promote herniation. In this setting, Josefsson et al. [ ] conducted an elegant study on the effect of division of the greater omentum during RYGB. Theirs is the first study to evaluate the success of this strategy in a large sample. They demonstrated in 40,517 patients that this surgical step significantly decreases the long-term incidence of SBO. At first glance, this appears to be great news: a rapid, relatively easy surgical maneuver to improve patient outcomes. Yet, there are several important potential criticisms that should be taken into consideration.