1. Introduction

Modern international studies indicate a steady increase in the prevalence of obesity and type 2 diabetes, and these two pathologies are considered interconnected epidemics of the 21st century [2]. The relevance of the problem is determined by the progressive increase in the prevalence of MO in combination with type 2 DM. According to WHO data, the global epidemic of excess weight currently affects 1.9 billion people, of which more than 300 million suffer from obesity [3]. Resolving these issues served as a reason for conducting this research.

The aim of the study is to improve the results of surgical treatment of obesity, including morbid obesity against the background of type 2 diabetes mellitus, by substantiating a differentiated approach to bariatric surgical interventions.

2. Research Material and Methods

The work is based on the results of a retrospective and prospective analysis of 159 patients with morbid obesity (MO) against the background of type 2 diabetes mellitus for the period from 2023 to 2024, who were subjected to surgical treatment at the "Sehat" private clinic in Andijan and the third surgical department of the Andijan State Medical Institute Clinic.

According to the goals and objectives of the study, it is conditionally divided into two groups:

- comparison group - (2023) - 57 (35.8%) patients, who underwent a retrospective analysis of the results of surgical treatment in compliance with traditional approaches;

- main group - (2024) - 102 (64.2%) patients, who underwent a prospective study of the results of surgical treatment using a differentiated approach to performing bariatric surgical interventions.

To achieve the goal and objectives of the study, general clinical, laboratory, biochemical, instrumental, and statistical research methods were used according to the protocols approved by the Ministry of Health of the Republic of Uzbekistan.

3. Results and Their Discussion

As clinical experience accumulated and the causes of "postbariatric complications" were analyzed in our team, GSH and PRJ surgery methods were modified, for which patents for invention IAP 7843 and IAP 20240549/1 PV of the RUz were obtained.

Modified laparoscopic mini-gastroschunt method for obesity against the background of type 2 diabetes mellitus (patent for invention No. IAP 7843 of the RUz dated 24.09.2024).

The essence of the method. A calibration probe with a diameter of 38 Fr is preliminarily inserted into the stomach, the same as during longitudinal gastric resection. A 30-50 ml stomach clamp (sponge) is formed according to the generally accepted method, however, the most important is that the stomach is cut at an angle of 30 degrees from the side of the lesser curvature towards the greater curvature. When the suturing device is applied, the fundus of the stomach is stretched by an assistant, creating a uniform entry of both the anterior and posterior walls into the resection line. In this case, the free movement of the tube along the lesser curvature into the stomach is controlled.

To prevent esophageal stricture, one should retreat 1-1.5 cm to the left of the gastroesophageal junction. The stomach cavity is not sutured, the stomach cavity is opened at the lower edge of the anterior wall of the sponge at the level of the anterior wall of the lesser curvature at the lower edge of the "goose paw" with a L-shaped hook, creating an opening up to 0.5 cm, which should interfere with the suturing apparatus. After determining the Traits ligament, 150 cm away from it, a biliopankreatic loop is formed. The branches of the laparoscopic clamp are 5 cm long. This size can serve as a benchmark for measuring the length of the small intestine [1].

Also, 4-5 cm from the future small intestine stump, along the opposite mesenteric edge, the intestinal wall is cut with a L-shaped hook (approximately 0.5 cm) to introduce a branch of the linear suturing apparatus. After 12 mm, a suturing apparatus is inserted into the right mesogastric port. The lower branch of the suturing apparatus is inserted into the small intestine opening in such a way that the upper branch grips the sponge wall within 3.5 cm. When the suturing apparatus is compressed, the posterior wall of the gastrointestinal anastomosis is formed with a stepler suture of no more than 3.5 cm long with blue or purple Coviden cassettes.

Before crossing the small intestine, it is advisable to check for the absence of tension in the intestinal mesentery. If tension is present, you can retreat 20-30 cm to one side or the other. The abducting loop is brought anteriorly to the formed "spider" (to the stomach appendix).

After removing the suturing apparatus, the stomach tube is advanced by the anesthesiologist, which ensures the tension of the stomach wall tissues and prevents accidental damage to its posterior wall during the incision of the anterior wall. After inserting the probe into the small intestine, the anterior wall of the gastroenteroanastomosis (technical opening) is sutured manually using a continuous single-row suture material V-loc - 3/0 under the control of the probe's mobility to prevent its suturing.

Then, to create conditions for the passage of gastric contents through the abducting loop and to prevent the return of gastric contents, a "spore" is created. Using the manual method, the leading loop is raised and sewn to the staple line with 3-4 stitches with 1.0 cm spacing, single-row stitches, and a monofilament absorbable thread V-loc 3/0.

After applying the gastroenteroanastomosis, the abductor and adductor intestines are compressed, retreating 10 cm from the gastroenteroanastomosis. The anastomosis area is filled with a physiological solution mixed with a brilliant green Janet syringe, after the solution is introduced into the probe, air is introduced through the Janet syringe with moderate intensity.

The stated method allows for the formation of a stump, where gastric contents enter only the abducting loop and prevent its contents from returning to the adducting loop by intersecting the stomach with an inclination from the side of the lesser curvature in the direction of the greater curvature at an angle of 30 degrees, as well as after forming a gastrojejunostomy at the medial edge of the stomach with a diameter of 3.5 cm, at an angle between the adducting loop and the stomach wall from the side of the greater curvature, the adducting loop is raised manually and sutured to the stepler line of the sponge with 3-4 sutures with an interval of 0.1-1.0 cm with single-row sutures, with a monofilament absorbable thread V-loc 3/0, which ensures the prevention of biliary reflux development, which allows avoiding repeated surgical intervention and thereby significantly improves the results of bariatric operations.

Modified Sleeve-resection method for obesity (patent for invention IAP 20240549/ 1 dated 04.04.2025).

When performing Sleeve-resection, a calibration probe with a diameter of 36 Fr is placed in the stomach beforehand. When the suturing device is applied, the fundus of the stomach is stretched by an assistant, creating a uniform entry of both the anterior and posterior walls into the resection line. In this case, the free movement of the tube in the stomach is controlled.

A reservoir of the gastric stump with a base in the antral section is formed in the form of a "calyx" with a diameter of 40-50 ml, which is created by cutting the stomach 4 cm from the pyloric jam in the medial direction, at an angle of 60 degrees to the calibration esophageal-gastric probe-buge. Then, at the junction of the 36 Fr diameter calibration esophageal-gastric probe-buge, the sleeve of the gastric stump is formed in the form of a "stem," where before applying the clips, the last (esophageal-gastric probe-buge) is mixed by the anesthesiologist in the distal and proximal directions, eliminating its suturing.

After sleeve resection, the cavity of the stomach is filled with a physiological solution mixed with 1% brilliant green solution through a Janet syringe with moderate intensity. With a negative test, the surgical intervention is completed according to generally accepted canons.

The proposed method allows for the passage of contents along the "stem" of the stomach cavity and in a more physiological delay in the "colba-like" expanded, distal part of the stomach cavity, which ensures the prevention of CRF, as well as insufficiency of the stomach cavity sutures. The method is characterized by simplicity and accessibility, with complete safety for the patient and minimal trauma. Prevention of GREIs, insufficiency of stitches along the gastric resection line, and repeated weight gain in the long-term period is ensured.

Thus, the introduction of "modified sleeve-resection" into morbid obesity surgery has leveled the development of "seam failure" of the resection line, GERD, and PNMT in the long term, contributes to the rapid recovery of patients, creates optimal conditions for healing, and is a highly effective method regardless of the degree of obesity, gender, and age. As a result, simple, accessible, minimally invasive, and safe methods eliminate stitching failure along the gastric resection line, prevent reflux esophagitis, and ensure repeated weight gain in the long-term period.

Modified method of using a calibrated esophageal-gastric tube depending on the degree of obesity against the background of type 2 diabetes mellitus.

It is important to note that with the accumulation of practical experience in performing bariatric surgical interventions in patients with varying degrees of obesity against the background of type 2 diabetes mellitus, as well as the analysis of immediate and long-term treatment results, there is a need for further optimization of the technical aspects of surgical interventions. One of the key elements influencing the effectiveness of the restrictive and metabolic components of bariatric interventions is the diameter of the esophageal-gastric calibration probe used.

In the previous stages of the work, during mini-gastric bypass surgeries and longitudinal gastric resection (Sleeve), the diameter of the calibrated esophageal-gastric tube was not differentiated depending on the degree of obesity, which in a number of cases could lead to insufficient restriction in patients with morbid obesity or, conversely, to excessive restriction in patients with less pronounced forms of obesity.

In this regard, to increase the effectiveness of surgical treatment and reduce the frequency of functional and metabolic complications, we have developed and implemented a modified method for using an esophageal-gastric calibration probe depending on the degree of obesity.

According to the proposed algorithm: in the first degree of obesity against the background of type 2 diabetes mellitus, the use of a 40 Fr diameter esophageal-gastric calibration probe is justified; in the second degree of obesity - the use of a 38 Fr diameter calibration probe; in the third degree of obesity (morbid obesity) - the use of a 36 Fr diameter calibration probe.

A differentiated approach to selecting the calibration probe diameter made it possible to more accurately adapt the volume of the formed gastric reservoir and the degree of restriction to the patient's initial anthropometric and metabolic characteristics.

Clinical and pathophysiological justification of DGU

The justification for the proposed modification is based on the fact that patients with varying degrees of obesity differ significantly in: stomach volume and its adaptive capabilities; severity of hyperphagia and eating disorders; degree of insulin resistance and hormonal-metabolic disorders; risk of functional complications (vomiting, reflux, stenosis, dumping syndrome).

The use of a wider calibration probe (40 Fr) in patients with the first degree of obesity allows avoiding excessive restriction, reduces the risk of postoperative dysphagia, gastroesophageal reflux, and nutritional disorders, while maintaining a sufficient metabolic effect. Conversely, in patients with second and especially third-degree obesity, reducing the calibration probe diameter to 38 Fr and 36 Fr provides adequate restriction, contributes to more pronounced and persistent weight loss, and potentiates the metabolic effect of the operation, including improvement of carbohydrate metabolism and type 2 diabetes compensation.

Thus, the proposed modified method allows for optimizing the balance between the effectiveness and safety of bariatric surgical interventions.

The introduction of differentiated use of the esophageal-gastric calibration probe is a logical continuation of the general concept of optimizing surgical tactics in patients with obesity against the background of type 2 diabetes mellitus. This modification complements the previously developed changes in the methodology of bariatric surgeries and is an important component of the improved treatment and diagnostic algorithm, aimed at individualizing treatment.

4. Conclusions

Thus, the introduction of modified methods of PRS and GS surgery into obesity surgery, including morbid obesity, contributed to a decrease in the frequency of life-threatening complications in the immediate postoperative period, and also improved the results of BOD in the long term, which is the subject of discussion in the following chapters of the dissertation. The developed and implemented modified method of differentiated use of the esophageal-gastric calibration probe depending on the degree of obesity made it possible to increase the effectiveness and safety of bariatric surgical interventions in patients with type 2 diabetes mellitus with obesity.

Individualization of the calibration probe diameter ensures the optimal level of restriction, reduces the risk of functional complications, and promotes more stable correction of metabolic disorders. In combination with other modifications of surgical tactics, this approach is an important element in optimizing surgical treatment and improving its immediate and long-term results.