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

Antral Preserving Versus Antral Resecting Laparoscopic Sleeve Gastrectomy for Patients with Severe Obesity: A Randomized Controlled Trial

BACKGROUND

This study aimed to compare outcomes following antral preserving (AP) and antral resecting (AR) laparoscopic sleeve gastrectomy (LSG) in terms of weight loss, gastric emptying time, gastroesophageal reflux disease (GERD), resolution of associated medical problems, and complications.

METHODS

Patients were prospectively randomized into two groups: the AR group (resection starting 2 cm from the pylorus) and the AP group (resection at 5 cm from the pylorus). Follow-up evaluations included assessments of weight loss using percentage of excess weight loss (%EWL) and percentage of total weight loss (%TWL), gastric emptying, GERD symptoms, associated medical problem resolution, residual gastric volume, and complications. Upper gastrointestinal endoscopy, gastric scintigraphy, and residual sleeve volumetry were conducted at 12 months.

RESULTS

One hundred patients who met inclusion criteria were enrolled, with comparable baseline parameters such as BMI, age, and comorbidities between the groups. Ninety-five patients underwent randomization (49 in AP group and 46 in the AR group), and outcomes were compared. %EWL was higher in the AR group at 12 and 24 months, although this difference was not statistically significant (AP vs. AR: 64.5 ± 20.6 vs. 72.9 ± 20.8, p = 0.1, and 66.3 ± 21.8 vs. 74 ± 22.2, p = 0.2, respectively). %TWL at 12 months was significantly different between the groups (AP: 28.4 ± 6.4 vs. AR: 32 ± 8, p = 0.01), as was %TWL at 24 months (AP: 29.1 ± 8.4 vs. AR: 33 ± 8.3, p = 0.01). Gastric emptying increased postoperatively in both groups, with significantly higher residual gastric volume in the AP group. Reflux symptoms decreased in both groups compared to baseline, and associated medical problem resolution and major complication rates were similar between the groups.

CONCLUSIONS

AR-LSG leads to better weight loss without increasing reflux symptoms compared to AP-LSG. Both procedures showed similar resolution of associated medical problems and complication rates.

TRIAL REGISTRATION

CTRI (CTRI/2018/08/015191).

Physiological Archetypes of de novo Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy (LSG) is the most common bariatric surgery in the world. While clinically effective, recent studies have shown increasingly higher rates of gastroesophageal reflux disease (GERD) and esophageal motility disorders. We reviewed all the literature and unraveled the underlying mechanism of post-LSG GERD. Finally, we propose a new classification to help us understand the disease and guide work-up, treatment, and future refinements in the surgical technique.

Surgical Aspects of Sleeve Gastrectomy Are Related to Weight Loss and Gastro-esophageal Reflux Symptoms

INTRODUCTION

A large variation in outcome has been reported after sleeve gastrectomy (SG) across countries and institutions. We aimed to evaluate the effect of surgical technique on total weight loss (TWL) and gastro-esophageal reflux disease (GERD).

METHODS

Observational cohort study based on data from the national registries for bariatric surgery in the Netherlands, Norway, and Sweden. A retrospective analysis of prospectively obtained data from surgeries during 2015-2017 was performed based on 2-year follow-up. GERD was defined as continuous use of acid-reducing medication. The relationship between TWL, de novo GERD and operation technical variables were analyzed with regression methods.

RESULTS

A total of 5927 patients were included. The average TWL was 25.6% in Sweden, 28.6% in the Netherlands, and 30.6% in Norway (p < 0.001 pairwise). Bougie size, distance from the resection line to the pylorus and the angle of His differed between hospitals. A minimized sleeve increased the expected total weight loss by 5-10 percentage points. Reducing the distance to the angle of His from 3 to just above 0 cm increased the risk of de novo GERD five-fold (from 3.5 to 17.8%).

CONCLUSION

Smaller bougie size, a shorter distance to pylorus and to the angle of His were all associated with greater weight loss, whereas a shorter distance to angle of His was associated with more de novo reflux.

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.

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.