Weight Loss Analysis According to Different Formulas after Sleeve Gastrectomy With or Without Antral Preservation: a Randomised Study

The impact of the bougie size and the extent of antral resection on weight-loss and postoperative complications following sleeve gastrectomy: results from the Scandinavian Obesity Surgery Registry

BACKGROUND

The optimal sleeve diameter and distance from the pylorus to the edge of the resection line in laparoscopic sleeve gastrectomy (LSG) remain controversial.

OBJECTIVES

To evaluate the influence of bougie size and antral resection distance from the pylorus on postoperative complications and weight-loss results in LSG.

SETTING

Nationwide registry-based study.

METHODS

This study included all LSGs performed in Sweden between 2012 and 2019. Data were obtained from the Scandinavian Obesity Surgery Registry. Reference bougie size of 35-36 Fr and an antral resection distance of 5 cm from the pylorus were compared to narrower bougie size (30-32 Fr), shorter distances (1-4 cm), and extended distances (6-8 cm) from the pylorus in assessing postoperative complications and weight loss as the outcomes of LSG.

RESULTS

The study included 9,360 patients with postoperative follow-up rates of 96%, 79%, and 50% at 30 days, 1 year, and 2 years, respectively. Narrow bougie and short antral resection distance from the pylorus were significantly associated with increased postoperative weight loss. Bougie size was not associated with increased early or late complications. However, short antral resection distance was associated with high risk of overall early complications [odds ratio: 1.46 (1.17-1.82, P = .001)], although no impact on late complications at 1 and 2 years was observed.

CONCLUSIONS

Using a narrow bougie and initiating resection closer to the pylorus were associated with greater maximum weight loss. Although a closer resection to the pylorus was associated with an increased risk of early postoperative complications, no association was observed with the use of narrow bougie for LSG.

Antral Preservation in Sleeve Gastrectomy Appears to Protect Against Prolonged Vomiting and Gastroesophageal Reflux Disease. A Meta-Analysis of Randomized Controlled Trials

The optimal distance between the starting point of gastric transection and the pylorus during laparoscopic sleeve gastrectomy (LSG), which can be referred to as the distance from pylorus (DFP), is controversial. No consensus exist for what DFP is considered antral preservation, and what DFP is considered antral resection. Some surgeons prefer shorter DFP to maximize excess weight loss percentage (EWL%), while others prefer longer DFP because they believe that it shortens length of stay (LOS) and protects against leaks, prolonged vomiting, and gastroesophageal reflux disease (GERD). We sought to compare 6-cm DFP and 2-cm DFP in postoperative outcomes. In addition, we sought to evaluate the magnitude of any observed benefit through number needed to treat (NNT) analysis.

A Program of Life-Style Modification Improved the Body Weight and Micronutrient Status in Obese Patients after Bariatric Surgery

INTRODUCTION

Bariatric surgery is an efficient approach to rapidly reduce morbid obesity and associated comorbidities. However, approximately one-fourth of patients experience weight and comorbidity recurrence, and both obesity and bariatric surgery can lead to micronutrient deficiencies. Implementing a structured program of lifestyle modification (PLM) might enhance weight loss and improve micronutrient status.

METHODOLOGY

A total of 121 severely obese patients underwent Roux-en-Y gastric bypass (RYGB). Among them, 71 adhered to a PLM involving dietary changes (low- and very-low-calorie Mediterranean diets) and physical exercises (aerobic and resistance training) both before and after surgery, while 50 patients followed a conventional protocol. Anthropometric measurements and serological parameter quantifications were conducted throughout the procedures.

RESULTS

The obese study population, primarily female (76.9%), with an average age of 47.11 ± 9.68, and a body mass index (BMI) of 44.68 ± 5.08 kg/m2, underwent either RYGB with a PLM or a conventional procedure. Before surgery, the PLM group exhibited significant reductions in body weight (6.3%) and phosphoremia compared to the conventional protocol (0.78%). Post-RYGB, the PLM group demonstrated shortened in-hospital stays and further BMI reductions (-16.12 kg/m2) that persisted for up to 2 years. Furthermore, the PLM group experienced increased plasma vitamin D levels (14.79 ng/mL vs. 1.2 ng/mL) for up to 2 years, as well as elevated folic acid (1.52 vs. -0.29 ng/mL) and phosphorus (0.48 vs. 0.06 mg/dL) levels at 1 month and 1 year after intervention, respectively. Notably, these effects were independent of weight loss.

CONCLUSIONS

Initiating a structured PLM from the early stages of patients' preparation for RYGB could enhance and extend the benefits of weight loss and positively impact micronutrient (vitamin D, phosphorus, and folic acid) status in obese patients.

The effect of antral resection start point on post sleeve gastrectomy gastroesophageal reflux symptoms and weight loss outcomes

PURPOSE

Sleeve gastrectomy (SG) has gained worldwide popularity by surgeons due to acceptable results in weight loss and obesity-associated medical problems. Distance from the pylorus during antral resection in SG may be effective in decreasing the occurrence of gastroesophageal reflux disease (GERD). The aim of this study was to evaluate GERD symptoms and weight loss outcomes in two groups of SG patients with different start points of antral resection.

METHODS

This is a prospective cohort study on 220 patients who underwent SG between June 2019 and July 2021, aged 18 and above, BMI ≥ 40 kg/m², or BMI > 35 kg/m² with at least one obesity-associated medical problem. According to the start point of antral resection the patients were divided in two groups (group A: from 2 cm of pylorus and group B: from 4 cm of pylorus). Evaluation of GERD was performed using GerdQ questionnaire at 12-month follow up.

RESULTS

Mean age and BMI of all patients were 37.6 ± 10 year and 44.8 ± 5.7 kg/m² at the time of SG. Totally 153(69.5%) of the patients were female. De novo GERD after 12 months in the groups A and B was found in 18 (20%) and 19 (21%) patients. TWL% at 12-month follow ups, were 33.9% and 32.5% in group A and B, respectively.

CONCLUSION

Antral resection's start point has no statistically significant effect on the excess and total weight loss indices, resolution of the obesity-related medical problems and De novo GERD between 2 and 4 cm start point for antral resection during SG.

Quality of Care Transition During Hospital Discharge, Patient Safety, and Weight Regain After Bariatric Surgery: a Cross-Sectional Study

PURPOSE

Bariatric surgery is established as the gold standard in the treatment of severe obesity. However, a significant proportion of patients experience a substantial weight regain afterwards. Previous research focused predominantly on patients' personal factors. Yet, critical discharge process factors that contribute to patient's adherence after surgical interventions are rarely examined. This study investigated whether high quality of care transitions in discharge management influences weight regain and the likelihood of experiencing adverse patient safety incidents.

MATERIALS AND METHODS

A cross-sectional study with 578 patients after bariatric surgery was conducted. Participants answered a standardized assessment on the quality of care transition from hospital to home-, surgery-, and nutrition-related characteristics as well as patient safety incidents.

RESULTS

Significant weight regain was observed 24 months after surgery. The association between time since surgery and weight regain was weaker in patients with high quality of care transitions (B = 2.27, p < .001). Higher quality of care transition was also significantly related to a lower likelihood of unplanned hospital readmissions (OR = 0.67) and fewer medication complications (OR = 0.48) after surgery.

CONCLUSION

This study sheds first light on the key influence of high quality of care transitions after bariatric surgery. Improvement efforts into effective discharge processes may establish smoother care transitions and help patients to assume responsibility and compliance with behavioral recommendations after surgery. Moreover, adverse patient safety incidents are less frequent after high quality care transitions indicating both high quality of health services for patients and reducing costs for the health care system.

Sleeve Gastrectomy: Does the Amount of Stomach Removed Matter?

PURPOSE

Data regarding the associations between percent weight loss and the volume and weight of stomach resected during sleeve gastrectomy (SG) are mixed. The purpose of this study was to evaluate the effect of the size and volume of stomach removed during laparoscopic SG on percent total body weight lost (%TBWL).

METHODS

An observational case series study was performed on 67 patients for 1 year after SG at a single university-affiliated, tertiary care hospital. Data were collected on demographics, medical history, and %TBWL at 3, 6, and 12 months post-operatively. Pearson's correlation matrices and multiple linear regression analyses were performed.

RESULTS

Most patients (88.1%) were female with a mean age of 44 years. The mean volume of stomach resected was 1047.0 cubic centimeters, and the median weight resected was 123.0 g. Follow-up data were available for 44 patients at 1-year post-operation. There was no association between the volume and weight of stomach resected and %TBWL at 1-year post-operation; however, greater %TBWL was associated with younger patient age (r =  - 0.525, p < 0.001).

CONCLUSION

One year after SG, no associations between %TBWL and the volume and weight of stomach resected were observed.

Laparoscopic Single Anastomosis Sleeve Ileal Bypass with Follow-up of Weight Loss and Metabolic Impact

Background: Bariatric surgery has been an effective safe management for severe obesity. The newly developed single-anastomosis sleeve ileal (SASI) bypass has shown efficacy as a functional as well as mechanical restrictive bariatric procedure, with a neuroendocrine modulation effect. SASI bypass is still an investigational procedure, hence, more evidence is needed till it is declared as a standard bariatric procedure by the IFSO. Aim of the study: The current work aimed to describe our experience regarding the technical steps, the efficacy and the short-term outcome of SASI bypass procedure in patients with severe obesity. Patients and methods: Forty seven patients with severe obesity underwent SASI bypass procedure. They were followed till 1 year postoperatively. The weight loss, comorbidities and laboratory changes were assessed. Results: Patients evaluation at the 1-year postoperative follow up revealed a mean %TWL of 37.55 ± 6.17 and a mean %EBWL of 76.21 ± 9.8. The remission rates of T2DM, hyperlipidemia and hypertension were 85.7%, 94.7% and 89.66%, respectively, with statistically high significant differences between the preoperative and 1-year postoperative comorbidities rate. Stepwise regression analysis demonstrated that only the preoperative HbA1C remained in the model predicting the %TWL, and the preoperative BMI was the remaining factor in the model predicting the %EBWL in the study patients. Conclusion: The present study adds a new evidence to the promising outcome of the newly introduced SASI bypass procedure. After one year, the study patients showed excellent weight loss and comorbidities remission together with acceptable major complication rates.

Antrum Preservation Versus Antrum Resection in Laparoscopic Sleeve Gastrectomy With Effects on Gastric Emptying, Body Mass Index, and Type II Diabetes Remission in Diabetic Patients With Body Mass Index 30-40 kg/m2: a Randomized Controlled Study

Background

Laparoscopic sleeve gastrectomy (LSG) is a widely performed procedure nowadays. There is a controversy on whether antrum resection (AR) or antrum preservation (AP) should be done and if this has an effect on BMI, gastric emptying, and associated medical conditions such as diabetes mellitus (DM).

Study Design

This randomized controlled trial included 56 patients in the AP group and 53 patients in the AR group with BMI 30–40 kg/m². Weight, BMI, fasting and postprandial blood glucose (FBS and PPBS), HbA1C, oral hypoglycemic drug use, and % gastric emptying by gastric scintigraphy at 30, 60, 90, and 120 min were recorded preoperatively and postoperatively at 3, 6, and 12 months. Postoperative % of total weight loss (TWL) and symptoms of de novo GERD were observed at 3, 6, and 12 months.

Results

The AR group had significantly lower BMI and HbA1C and higher %TWL than the AP group. There was a significant difference between the two groups regarding % of gastric emptying with the AP group showing higher values at 30, 60, 90, and 120 min. There were no significant differences regarding FBS, PPBS, and oral hypoglycemic use. The AR group had more incidence of GERD symptoms postoperatively yet with no significant difference.

Conclusion

LSG with antrum resection (2 cm from the pylorus) had significantly less postoperative BMI, higher %TWL, better control of type II DM, and more retention of gastric contents in patients with BMI 30–40 kg/m² in comparison with LSG with antral preservation with non-significant increase in incidence of GERD symptoms.

Graphical abstract

Outcomes of laparoscopic sleeve gastrectomy with and without antrectomy in severely obese subjects. Evidence from randomized controlled trials

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) has been proven safe and effective in achieving weight loss. However, the distance from the pylorus where resection should begin has been debated.

OBJECTIVES

To compare the clinical outcomes of laparoscopic SG with antrum resection (AR) versus preservation (AP) for bariatric purposes by conducting a meta-analysis of randomized controlled trials (RCT).

SETTING

Academic hospital, United States.

METHODS

PubMed and Cochrane Library were queried for RCTs from establishment to August 2020. The following key search terms were used: "sleeve gastrectomy" AND ("antrectomy" OR "antrum") AND ("randomized" OR "random"). The following data were extracted: author, publication year, country, sample size, follow-up duration, and clinical outcomes, including weight-related: excess weight loss (EWL), total weight loss (TWL), body mass index (BMI), operation time, length of hospital stay, complication rates, and resolution of obesity-related comorbidities.

RESULTS

A total of 9 unique RCTs including 492 AR and 385 AP patients were screened and included in the final quantitative analysis. Patients who underwent SG with AR showed higher EWL and TWL at 6 months (EWL: P < .001; TWL: P = .006), and 1 year (EWL: P = .013; P < .001) postoperatively. The BMI was also lower in the AR group 3 months (P = .013) and 6 months (P = .003) postoperatively. However, the EWL and BMI at 2 years were comparable between both groups (P = .222 and P = .908, respectively). No statistical significance was observed in terms of operating time, staple line disruption, bleeding, complications with a Clavien-Dindo Grade >III, resolution of comorbidities (hypertension, diabetes, hyperlipidemia, arthritis/back pain), and de novo gastroesophageal reflux disease (P > .05). AP was associated with a slightly shorter postoperative hospital stay (4.0 versus 3.1 days, P = .039).

CONCLUSION

Laparoscopic SG with AR is associated with superior weight loss in the short-term compared with AP. However, mid-term follow-up beyond 1 year showed no significant differences in BMI or incidence of de novo gastroesophageal reflux disease.

Long-Term Weight Outcomes after Bariatric Surgery: A Single Center Saudi Arabian Cohort Experience

Background: Obesity is considered a global chronic disease requiring weight management through lifestyle modification, pharmacotherapy, or weight loss surgery. The dramatic increase in patients with severe obesity in Saudi Arabia is paralleled with those undergoing bariatric surgery. Although known to be beneficial in the short term, the long-term impacts of surgery within this group and the sustainability of weight loss after surgery remains unclear. Objectives: We aimed to assess the long-term weight outcomes after bariatric surgery. Setting: The study was conducted at King Khalid University Hospital (KKUH), King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia. Methods: An observational prospective cohort study on adult patients with severe obesity undergoing bariatric surgery (sleeve gastrectomy (SG) or Roux-en Y gastric bypass (RYGB)) during the period between 2009 and 2015 was conducted. Weight loss patterns were evaluated pre- and post-surgery through clinical and anthropometric assessments. Absolute weight loss was determined, and outcome variables: percent excess weight loss (%EWL), percent total weight loss (%TWL), and percent weight regain (%WR), were calculated. Statistical analysis using univariate and multivariate general linear modelling was carried out. Results: A total of 91 (46 males and 45 females) patients were included in the study, with the majority belonging to the SG group. Significant weight reductions were observed at 1 and 3 years of follow-up (p < 0.001) from baseline. The %EWL and %TWL were at their maximum at 3 years (72.4% and 75.8%) and were comparable between the SG and RYGB. Decrements in %EWL and %TWL and increases in %WR were seen from 3 years onwards from bariatric surgery until the study period ended. The yearly follow-up attrition rate was 20.8% at 1 year post-surgery, 26.4% at year 2, 31.8% at year 3, 47.3% at year 4, 62.6% at year 5, and 79.1% at end of study period (at year 6). Conclusion: The major challenge to the successful outcome of bariatric surgery is in maintaining weight loss in the long-term and minimizing weight regain. Factors such as the type of surgery and gender need to be considered before and after surgery, with an emphasis on the need for long-term follow-up to enssure the optimal benefits from this intervention.

Geometry of Sleeve Gastrectomy Measured by 3D CT Versus Weight Loss: Preliminary Analysis

BACKGROUND

The size of the remnant stomach with respect to weight loss failure after laparoscopic sleeve gastrectomy (LSG) remains controversial. This study aimed to evaluate the impact of the actual size and volume of the remnant stomach, as measured by three-dimensional computed tomography (3D-CT) volumetry, on weight loss after LSG.

METHODS

The clinical outcomes of 52 patients who underwent LSG between October 2008 and February 2019 were assessed. Weight metrics were recorded at 1, 3, and 6 months and 1 year postoperatively. 3D-CT volumetry was performed 1 year postoperatively, and the total remnant stomach volume (TSV), proximal stomach volume (PSV), antral stomach volume (ASV), and the distance between the pylorus and the distal edge of staple line (DPS) were measured. The relationship between the weight metrics and aforementioned factors was analyzed.

RESULTS

Of the 52 patients who underwent LSG, 40 patients participated in this study. The average body mass index preoperatively was 38.3 ± 5.1 kg/m², and the average percentage of total weight loss (%TWL) 1 year after LSG was 26.6 ± 9.3%. The average TSV, PSV, ASV, and DPS were 123.2 ± 60.3 ml, 73.4 ± 37.2 ml, 49.8 ± 30.3 ml, and 59.9 ± 18.5 mm, respectively. The DPS (r = - 0.394, p = 0.012) and ASV (r = - 0.356, p = 0.024) were correlated with %TWL 1 year postoperatively.

CONCLUSIONS

The actual DPS and ASV measured by 3D-CT affected weight loss after LSG. 3D-CT may be useful for the immediate identification of factors affecting insufficient weight loss in patients; this may, in turn, aid in the implementation of early intervention treatments.

The role of extended antral resection on weight loss and metabolic response after sleeve gastrectomy: A retrospective cohort study

Objective:

The impact of extended antral resection (AR) after laparoscopic sleeve gastrectomy (LSG) on clinical results is still not clearly elucidated with conflicting results. Our study aimed to determine whether AR is superior to antral preservation (AP) regarding clinical results.

Methods:

Patients were divided into two groups according to the distance of gastric division as AR group (2cm from pylorus) and AP group (6cm from pylorus). Postoperative excess weight loss percentile (%EWL) and total body weight loss percentiles (%TBWL) at the end of first, 6^th and 12 months were compared. Secondly, metabolic parameters and complications were compared.

Results:

The first 68 patients underwent AP, and the following 43 patients underwent AR. Although statistically not significant, AR achieve more %EWL and %TBWL at the end of the first year, (P>0.05). On the other hand, metabolic parameters were similar at the end of the first year, (P>0.05). Resolution of comorbidities were statistically not different, (P>0.05). Staple line leak occurred in two patients of the AR group (4.7%) and two patients of the AP group (2.9%), (P>0.05).

Conclusion:

Both AR and AP seem to be equally effective in resolution of metabolic response. Although statistically not significant- AR provided more %EWL and %TBWL at the end of 12 months.

Thyroid Hormone Changes After Sleeve Gastrectomy With and Without Antral Preservation

BACKGROUND

The effect of bariatric surgery on thyroid hormone changes yielded inconsistent results. The aim of the present study was to assess the change of thyroid hormone levels following laparoscopic sleeve gastrectomy (LSG), with or without antral preservation (AP).

METHODS

Thyroid hormones (TSH, FT3, FT4) were examined preoperatively, at the end of the first postoperative month, and first postoperative year. Secondly, antral resection (AR) and AP were compared at inducing weight loss and thereby affecting thyroid hormone levels.

RESULTS

Euthyroid obese patients (86 female/20 male) underwent LSG. Of these, 58 patients underwent AR and 48 patients AP. The mean FT3 levels significantly decreased both in the first postoperative month and the first year (P < 0.001), whereas mean TSH levels decreased significantly in the first postoperative year (P < 0.001). FT4 levels remained nearly unchanged (P = 0.517). Postoperative first year body mass index (BMI) loss, excess BMI loss percentile (%EBMIL), and total body weight loss percentile (%TWL) were significantly higher in AR group than the AP group (P ≤ 0.01). When the change in thyroid hormone levels was analyzed by pyloric distance according to time periods, no significant difference was found in TSH and FT4 levels (P > 0.05); however, reduction in FT3 levels was significantly greater in patients with AR than in AP patients (P = 0.028).

CONCLUSION

LSG promotes significant reduction in TSH and FT3 levels, whereas FT4 levels remain unchanged. LSG with AR provides more weight loss in short term and appears to be more effective at lowering FT3 levels.

Food Tolerance After Laparoscopic Sleeve Gastrectomy with Total Antral Resection

BACKGROUND

Among the controversial points in laparoscopic sleeve gastrectomy (LSG) is how much of the antrum to be resected. This study aimed to evaluate food tolerance after preservation or resection of the antrum during LSG.

METHODS

Prospective randomized study included 50 patients scheduled for LSG. Participants were randomly allocated into one of two groups. In antral resection (AR-LSG) group (n = 25), resection started 2 cm from the pylorus. In antral sparing (AS-LSG) group (n = 25), it started 6 cm from the pylorus. Percentage of excess weight loss (%EWL) and percentage of excess BMI loss (%EBL) were evaluated after 3 and 6 months. Quality of life (QOL) was evaluated by using the Bariatric Analysis and Reporting Outcome System (BAROS). Food tolerance was assessed using the Quality of Alimentation questionnaire. Primary outcome measure was food tolerance and %EWL.

RESULTS

Food tolerance was significantly better in the antral sparing group compared to the antral resection group after 3 and 6 months. The two groups were comparable in %EWL and BMI change after 3 and 6 months. Six months after surgery, the majority of patients had a very good quality of life, with no significant difference between the two groups (p = 0.877). There was no significant difference between the two groups in operative time, intraoperative blood loss, and hospital stay.

CONCLUSIONS

Preservation of the pyloric antrum during LSG is associated with significantly better food tolerance and comparable effect of weight loss up to 6 months postoperatively when compared with total antral resection.

Presurgical Predictive Factors of Excess Weight Loss After Laparoscopic Sleeve Gastrectomy

PURPOSE

Conditions associated with surgical technique and postoperative lifestyle changes, as well as the characteristics of patients, may affect weight loss following laparoscopic sleeve gastrectomy. In this study, the effects of age, gender, BMI, and excess weight at the time of surgery on weight loss during follow-up were examined.

MATERIALS AND METHODS

Demographic data (age, gender), preoperative BMI, and weight values of the patients were recorded. TWL% and EWL% values of patients were recorded during follow-up at 1st, 3rd, 6th, 9th, 12th, and 18th months. Patients were grouped according to age (AGE1 < 30, AGE2 30-50, AGE3 ≥ 50 years), BMI at the time of surgery (BMI1 ≤ 50, BMI2 > 50 kg/m²), and EW at the time of surgery (EW1 ≤ 60, EW2 > 60 kg). EWL% values obtained in the follow-up visits were compared among the gender, age, BMI, and EW groups.

RESULTS

A total of 456 patients (371 females, 85 males) were operated. Mean EWL% was lower in AGE3 group (p < 0.001). Patients in AGE1 group had the highest mean EWL%, while those in BMI2 and EW2 groups had lower mean EWL% values throughout the follow-up period (p < 0.001). Regression analysis showed that age and BMI were associated with EWL% at all follow-up visits (p < 0.05).

CONCLUSION

Patients with less than 60 kg of excess weight, those with BMI ≤ 50 kg/m² and younger patients may lose weight more effectively following LSG.

Update: 10 Years of Sleeve Gastrectomy-the First 103 Patients

BACKGROUND

Sleeve gastrectomy (SG) has been the most frequently performed bariatric procedure worldwide since 2014. Therefore, it is vital to look at its outcomes in a long-term follow-up based on a large patient collective. Main points of discussion are weight regain, reflux, and patients' quality of life at 10+ years after the procedure.

OBJECTIVES

The aim of this study is to present an update of data that have been published recently and, thus, achieve more conclusive results. The number of patients has been doubled, and the length of the follow-up is still 10+ years.

SETTING

Multi-center study, medical university clinic, Austria METHODS: This study includes all patients who had SG before December 2006 at the participating bariatric centers. At 10+ years, non-converted patients (67%) were examined using gastroscopy, manometry, 24-hour pH-metry, and questionnaires. Patients' history of weight, comorbidities, and reflux were established through interviews.

RESULTS

At 10+ years after SG, the authors found a conversion rate of 33%, an %EWL in non-converted patients of 50.0 ± 22.5, reflux in 57%, and Barrett's metaplasia in 14% of non-converted patients. Gastroscopies revealed that patients with reflux were significantly more likely to have de-novo hiatal hernia. A significantly lower quality of life was detected through GIQLI and BAROS in patients with reflux.

CONCLUSION

The authors recommend gastroscopies at 5-year intervals after SG to detect the possible sequelae of reflux at an early stage. Conversion to Roux-en-Y-gastric bypass (RYGB) works well to cure patients from reflux but may not be as efficient at treating weight regain.

Analysis of Gastric Physiology After Laparoscopic Sleeve Gastrectomy (LSG) With or Without Antral Preservation in Relation to Metabolic Response: a Randomised Study

INTRODUCTION

Laparoscopic sleeve gastrectomy is one of the most common techniques in bariatric surgery, but there is no consensus on the optimal distance from the pylorus to start the gastric transection. The aim of this study is to determine the differences in gastric emptying, gastric distension and metabolic response between two starting distances.

MATERIAL AND METHODS

This is a prospective randomised study of 60 patients (30 patients with the section at 3 cm and 30 patients at 8 cm from the pylorus). We calculate at 6 and 12 months from surgery gastric emptying by scintigraphy (T1/2 min), gastric volume by CT scan (cc) and metabolic response by blood sample analysis (glucose, HbA1c, insulin, HOMA-IR, GLP-1, GIP and C-peptide).

RESULTS

Gastric emptying increases the speed significantly in both groups but is greater in the 3-cm group (p < 0.05). Dividing groups into type 2 diabetic patients and non-diabetic patients, the speed in non-diabetic patients is significantly higher for the 3-cm group. Residual volume increases significantly in both groups, and there are no differences between them. One year after surgery, there are significant improvements in the hyperinsulinaemia in the patients of the 3-cm group with respect to the 8-cm group, but only in diabetic patients. No differences between groups are found regarding changes in GLP-1 or GIP.

CONCLUSIONS

Gastric emptying is faster in patients with antrum resection. The distance does not influence the gastric emptying of diabetic patients. Other mechanisms may explain metabolic response besides GLP-1 and its association with improvements in diabetes via gastric emptying.

Antral resection versus antral preservation during laparoscopic sleeve gastrectomy for severe obesity: Systematic review and meta-analysis

Although laparoscopic sleeve gastrectomy is an established operation for severe obesity, there is controversy regarding the extent to which the antrum is excised. The objective of this systematic review was to investigate the effect on perioperative complications and medium-term outcomes of antral resecting versus antral preserving sleeve gastrectomy. MEDLINE, EMBASE, and Cochrane databases were searched from 1946 to April 2017. Eligible studies compared antral resection (staple line commencing 2-3 cm from pylorus) with antral preservation (>5 cm from pylorus) in patients undergoing primary sleeve gastrectomy for obesity. Meta-analyses were performed with a random-effects model, and risk of bias within and across studies was assessed using validated scoring systems. Eight studies (619 participants) were included: 6 randomized controlled trials and 2 cohort studies. Overall follow-up was 94% for the specified outcomes of each study. Mean percentage excess weight loss was 62% at 12 months (7 studies; 574 patients) and 67% at 24 months (4 studies; 412 patients). Antral resection was associated with significant improvement in percentage excess weight loss at 24-month follow-up (mean 70% versus 61%; standardized mean difference .95; confidence interval .35-1.58, P<.005), an effect that remained significant when cohort studies were excluded. There was no difference in incidence of perioperative bleeding, leak, or de novo gastroesophageal reflux disease. According to the available evidence, antral resection is associated with better medium-term weight loss compared with antral preservation, without increased risk of surgical complications. Further randomized clinical trials are indicated to confirm this finding.