Different surgical options are available for patients with an initial suboptimal response or a late recurrence after a sleeve gastrectomy. Duodeno-ileostomy is a simple and effective option that eliminates the need of a Roux-en-Y, thanks to the pyloric preservation. The operation has demonstrated to be very effective and safe as a primary surgery. Either as a second step surgery or as a salvage operation after the sleeve gastrectomy is technically easy, as it only needs antral and duodenal dissection and a duodeno-intestinal end-to-side anastomosis. Reported results from different groups outweigh those of gastric bypass or re-sleeve, with comparable complication rates. Different length of common channel can be employed and should be selected upon the patient’s characteristics. Supplementation has to be maintained for life to avoid nutritional issues.