Antral Resection Research Articles

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.

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

BackgroundThe optimal sleeve diameter and distance from the pylorus to the edge of the resection line in laparoscopic sleeve gastrectomy (LSG) remain controversial. ObjectivesTo evaluate the influence of bougie size and antral resection distance from the pylorus on postoperative complications and weight-loss results in LSG. SettingNationwide registry-based study. MethodsThis 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. ResultsThe 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. ConclusionsUsing 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.

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. This is a prospective cohort study on 220 patients who underwent SG between June 2019 and July 2021, aged 18 and above, BMI ≥ 40kg/m2, or BMI > 35kg/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 2cm of pylorus and group B: from 4cm of pylorus). Evaluation of GERD was performed using GerdQ questionnaire at 12-month follow up. Mean age and BMI of all patients were 37.6 ± 10year and 44.8 ± 5.7kg/m2 at the time of SG. Totally 153(69.5%) of the patients were female. De novo GERD after 12months 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. 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 4cm start point for antral resection during SG.

Evaluation of postprandial symptoms in two different laparoscopic sleeve gastrectomy techniques using gastric emptying scintigraphy

Laparoscopic sleeve gastrectomy (LSG) is a frequently used procedure in the surgical treatment of obesity in recent years. However, surgeons have different opinions regarding the distance from the antrum to the pylorus. In addition, postprandial symptoms significantly affect the overall quality of life. Therefore, this study aimed to understand the relationship between postprandial symptoms with gastric emptying time and surgical procedures. Sixty patients who underwent LSG surgery were analyzed retrospectively and divided into two groups: antrum preserved (AP) and antrum resected (AR). The antral resection margin was 2 cm from the pylorus in 35 patients (AR group) and 6 cm in 25 patients (AP group). Semisolid gastric emptying scintigraphy (GES) was performed prospectively in both groups. Postprandial symptoms were standardized with a questionnaire. The relationship of symptoms with a half time of gastric emptying (GE T½), retention percentage at 30 and 60 minutes, lag phase, body mass index (BMI), and a decline in excess weight (% EWL), and antrum resection were investigated. The obtained results were compared between the two groups and with the control group. The study group comprised 60 patients (49 F/11 M, mean age: 40.3 ± 20.1 years, BMI 31.6 ± 8.1 kg/m2). The half-time of gastric emptying in the AR and AP groups (28.00 min ± 9.58, 28.24 min ± 11.90, respectively), percentage gastric retention at 30 and 60 minutes in the AR and AP groups (30 minutes: %44.37 ± 17.88, %40.52 ± 14.56 and 60 minutes: 17 ± 8.9, 19 ± 3.1) was significantly different compared with the control group, but no significant difference was observed between the study groups. In addition, there was no statistically significant difference between the AR and AP groups in postprandial symptom scores >9 (68.6%, 60%, P = 0.681), GER (77.1%, 64%, P = 0.253), and postoperative BMI (p = .397), % EWL (p = .975), and T lag phase (p = .332). In our study, the postprandial symptoms were not affected between two different surgical procedures in LSG.

The Effects of Antral Preservation and Antral Resection on Body Composition, Glycemic Control and Bone Mineral Density Following Vertical Sleeve Gastrectomy in C57BL/6J Mice with Obesity and Type 2 Diabetes.

PurposeSleeve gastrectomy (SG) is the most currently popular operation for obesity and related metabolic disorders. The aim of this study was to compare the effect of antrum preservation SG (AP-SG) and antrum resection SG (AR-SG) on the body composition, glycemic control and bone mineral density (BMD) in mice.MethodsSham, AP-SG and AR-SG operation were performed on obese and T2D C57BL/6J mice (8 in each group). Body weight, food intake, and fasting glucose (FG) levels were measured at the 0, 2, 4, 6 and 8 weeks post-operatively. Oral glucose tolerance test (OGTT) was performed preoperatively and at the eighth postoperative week. The body fat content and total body BMD were evaluated by dual-energy x-ray absorptiometry. After being euthanized, the femurs were harvested and analyzed by micro-CT.ResultsThe improvements in body weight, food intake, FG, glycemic control and body fat were statistically significant following AP-SG and AR-SG. Both AP-SG and AR-SG groups decreased total body BMD and regional BMD in the distal femur compared to the sham group. No significant difference of FG was observed in AP-SG and AR-SG group postoperatively, but AR-SG showed significantly superior OGTT glucose AUC than AP-SG. Except for a lower BMD, AR-SG achieved superior outcomes in body fat and glycemic control than AP-SG.ConclusionAntrum resection SG shows a lower percentage of body fat and better glycemic control than antrum preservation SG. However, antrum resection SG has a higher risk of having a lower bone mass. Further human clinical trials are needed to confirm this finding.

The Effect of Antrum Size on Weight Loss, Glucagon-Like Peptide-1 (GLP-1) Levels, and Glycemic Control Following Laparoscopic Sleeve Gastrectomy in Adolescents with Obesity and Type 2 Diabetes.

The aim of this study was to compare the effect of antral resection versus antral preservation sleeve gastrectomy on the post-operative GLP-1, glycemic control, and weight loss in adolescents suffering from severe obesity and type 2 diabetes (T2D). This study included 36 adolescents. Patients were randomly divided into 2 groups: group (A) and group (B). Each group included 18 patients who underwent LSG, starting transection at 2 cm or 5 cm from the pyloric ring in group (A) and group (B), respectively. They were followed up at 1, 3, 6, 12, and 24 months post-operatively. The outcomes were the post-operative GLP-1 response, glycemic control, weight loss, and safety. The improvements in the body mass index and the percentage of excess weight loss (%EWL) were statistically significant within each group. The mean GLP-1 levels showed significant increase at the 1, 3, and 6 months but not in the 12 and 24 months in all the studied samples within each group. The mean HbA1c levels and post-prandial serum C-peptide significantly improved within each group (P < 0.05). No statistical differences in the weight loss, %EWL, GLP-1, HbA1c, C-peptide changes, and complication rates were observed between both groups. Diabetic remission was significantly higher (88.9%) in group (A). LSG resulted in generalized significant GLP-1 initial response that decreased over time. The reduced antrum size did not influence the GLP-1 response, glycemic control, or insulin resistance, but resulted in significantly better T2D remission. Since the study examines a small number of patients, further studies are needed. ClinicalTrials.gov Identifier: NCT04388059.

Laparoscopic Sleeve Gastrectomy: 2 cm versus 6 cm Distance from the Pylorus

Background:The objective of this prospective randomized study was to study the effect of the residual gastric antrum size on the outcome of laparoscopic sleeve gastrectomy and to evaluate the effect of antral resection on weight reduction and complications after LSG.Patients and Methods: Sixty patients underwent LSG as a primary bariatric procedure from November 2016 to March 2019 were randomized into two groups depending on the distance from the pylorus at which gastric division begins. In group (A), the distance was 2 cm from the pylorus, whereas the distance was 6 cm in group (B). The follow-up period was at least 6 months. Baseline and 3 and 6 month outcomes were analyzed including assessments of the percent excess weight lost (% EWL), reduction in BMI, morbidity, mortality, reoperations, quality of life, and co-morbidities.Result(s): Sixty patients included in this study, whose mean pre-operative age was (32.48± 7.92) years, three (5%) patients were males and 57(95%) patients were females with a mean pre-operative BMI was (53.45 ± 8.00) Kg/m2. In group A, the mean % EWL was (33.1 ± 7.15) and (51.37 ± 8.57) at 3 and 6 months respectively. In group B the mean % EWL was (29.29 ± 6.1) and (46.44 ± 9.85) at 3 and 6 months respectively. Patients with the first staple line started 2 cm from the pylorus had better weight loss than those started 6 cm from the pylorus after 3 and 6 months, but this difference statistically insignificant.Conclusion(s): LSG with 2 cm or 6 cm first staple firing from the pylorus produces significant weight loss after surgery. The 2 procedures are equally effective regarding %EWL, morbidity, quality of life, and improvement of co-morbiditieswith insignificant superiorities of 6 cm group.

Management of anatomical challenges during laparoscopic cephalic duodenopancreatectomies

Introduction: Laparoscopic cephalic duodenopancreatectomy (LCDP) is considered a surgery of high technical complexity. It has a long learning curve because of the need of high laparoscopic technical skills, especially in the presence of anatomical variations. The aim of this video is to present three cases of LDCP (pure and hybrid) with difficult anatomical challenges and how to approach them. Case 1: A 76 years old woman presents with painless jaundice and workup reveals an infiltrating 20 mm adenocarcinoma of the Vater´s ampulla. During LCDP, a right posterior bile duct draining independently distal to the common bile duct is found, so two-separated laparoscopic bilio-enteric anastomosis are performed. Case 2: A 70 years old men presents with painless jaundice and workup reveals a 30 mm dysplastic adenoma of the Vater´s ampulla. He had a surgical history of an open gastric antral resection due to a perforated peptic ulcer 40 years ago. During LCDP, multiple lysis adhesions of the hepatic hilium are required and a right hepatic artery arising from the superior mesenteric artery is identified and preserved. Case 3: A 70 years old men with Child-B cirrhosis presents with jaundice and workup reveals an adenocarcinoma of the Vater´s ampulla not suitable for endoscopic resection. Hepatic venous gradient pressure (HVGP) measurement is 7 mmHg, so after multidisciplinary discussion a hybrid LCDP is performed with no complications. Conclusion: anatomical challenges can be safely approached under laparoscopic surgery during LCDP.

The rapid effects of sleeve gastrectomy on glucose homeostasis and resolution of diabetes mellitus.

AimsType 2 diabetes caused by obesity is increasing globally. Bariatric surgical procedures are known to have positive effects on glucose homeostasis through neurohormonal action mechanisms. In the present study, we aimed to investigate the factors influencing glucose homeostasis independent of weight loss after the laparoscopic sleeve gastrectomy (LSG).MethodsPatients who underwent LSG for morbid obesity in a 3‐year period were evaluated. Data on demographics, clinical characteristics (duration of diabetes, resected gastric volume, antral resection margin) and laboratory parameters (preoperative and postoperative blood glucose on fasting, preoperative HbA1c levels and first‐year HbA1c levels) were retrospectively reviewed. Effect of patients' body mass index (<50 kg/m2, ≥50 kg/m2), first‐year excess weight loss (EWL%) rates, age (≥50 years, <50 years), duration of diabetes (≥5 years, <5 years) and antral resection margin (≥3 cm, <3 cm) on postoperative blood glucose profile and diabetic resolution status were investigated.ResultsTotal of 61 patients constituted the study group. There were 40 female and 21 male patients with an average age of 43.8 ± 10.5 years (19‐67 years). Preoperatively, mean BMI, blood glucose levels and HbA1c were 48.8 ± 8.5 kg/m2, 133.6 ± 47.4 mg/dL and 7.4 ± 1.1, respectively. The mean blood glucose level at the postoperatively 5th day was 88.0 ± 16.3 mg/dL (median: 84 mg/dL) (P < .001). Fifty‐nine out of 61 patients improved their glycaemic control.ConclusionsIt is noteworthy that LSG can control blood glucose levels in short term after surgery regardless of weight loss. Therefore, LSG should be preferred at earlier stages in the treatment of obesity‐related T2DM in order to prevent T2DM‐related complications.

Thyroid Hormone Changes After Sleeve Gastrectomy With and Without Antral Preservation.

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). 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. 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). 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.

Evaluating the impact of the antrum size following laparoscopic sleeve gastrectomy: a randomized multicenter study.

The effect of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) remains discordant and highly related to the surgical technique. GERD and weight regain are probably understudied by prospective clinical studies depending on different technical factors. The purpose of this article is to evaluate the effect of extent to which the antrum is resected on GERD following LSG but also on early complications and short-term weight loss results. University Hospital, France. Patients were randomly assigned in group A (172 patients), LSG with antral resection, or group B (174 patients), LSG with antral preservation. The baseline characteristics collected were demographic characteristics and anthropometric data (age, sex, body mass index), presence of GERD clinical characteristics, ± pH-metry, postoperative complications, or gastrin level. A total of 279 patients underwent LSG and they were included in the final analysis. The GERD analyzed at 3 months postoperatively by pH-metry was observed for 57.8% in group A and for 52.4% of patients in group B (P = .4819). There was no statistically significant difference (P = .3755) between the 2 groups at 1 year after surgery (group A, 49.5% versus group B, 43.6%). The gastrin serum level was analyzed 1 year after surgery for a total of 107 patients. For group A, the mean gastrin level was 97.4 ± 85.9 pg/mL, which was inferior compared with group B (150.6 ± 152.4 pg/mL) with no statistical difference (P = .067). The recorded excess weight loss for group A was 79.67% (± 28.88) with no statistically significant difference with group B 74.46% (± 36.61) (P = .3678). The mortality rate was nil. We recorded 5 cases of staple line leakage (3 in group A and 2 in group B); 11 patients presented bleeding (3 in group A and 8 group B), and 4 patients presented with gastric stenosis (2 in group A and 2 in group B). The antrum preservation has no significant difference in terms of reflux, weight loss, or complications at 3 or 12 months following LSG. The only significant difference was achieved for nausea and vomiting symptoms, which were more significant for the antrum resection group. Further clinical trials with newer procedures will indicate the factors that can diminish the reflux following LSG. Furthermore, the conservation of a large part of the antrum may be helpful to convert the sleeve to another bariatric procedure (transit bipartition).

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, 6th 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.

The Role of Extended Antral Resection on Weight Loss and Metabolic Response After Sleeve Gastrectomy

The Role of Extended Antral Resection on Weight Loss and Metabolic Response After Sleeve Gastrectomy

Impact of Laparoscopic Sleeve Gastrectomy on Gastric Emptying, Our Institutional Experience in Ain Shams University

Background: Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed procedure in the world and has overtaken the “gold standard” Roux-en-Y gastric bypass (RYGB) Obesity. The abstraction of the fundus is linked to physiological changes in gastric motility, as the gastric pacemaker is removed. Variable distance of antral resection from the pylorus is present in most cases. This is expected to provoke alterations in gastric emptying. Aim of the Work: to assess the changes in gastric emptying after sleeve gastrectomy and determine the time needed for accommodation. Recommendation of prokinetic therapy was or not reached after this study. Patients and methods: 30 morbidly obese patients who underwent LSG. 99mTc–sulfur colloid GE scintigraphy was performed on all patients pre and post-surgery. All operations were standardized regarding bougie size and distance of antral resection. Results: The mean preoperative body mass index BMI is 44.65±4.26 kg/m2 (range, 40 - 53) and the mean preoperative body weight is 123.90±14.79 kg (range, 105 - 155). accelerated gastric emptying presented in 24 cases, delayed emptying in 3 cases and normal emptying in 3 cases. The mean preoperative percent of retention at 30 min was 71.83±14.83 (range, 41.6 – 92) decreased to 57.88±12.66 (range, 38.1 – 80.1) after 3 months, and a mean percent of retention at 30 min was 57.45±21.41 (range, 18.7 - 85.2) after 6 months. Conclusion: Gastric emptying was significantly accelerated after sleeve gastrectomy with application of tight bougie (36 French size) and preservation of the antrum. There was strong correlation between delayed gastric emptying and appearance of postprandial symptoms which subsided after prokinetic therapy. However, further studies are required for comparison between tight and wide bougie as regards their effect on gastric emptying and weight regain.

Food Tolerance After Laparoscopic Sleeve Gastrectomy with Total Antral Resection.

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. 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 2cm from the pylorus. In antral sparing (AS-LSG) group (n= 25), it started 6cm from the pylorus. Percentage of excess weight loss (%EWL) and percentage of excess BMI loss (%EBL) were evaluated after 3 and 6months. 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. Food tolerance was significantly better in the antral sparing group compared to the antral resection group after 3 and 6months. The two groups were comparable in %EWL and BMI change after 3 and 6months. 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. Preservation of the pyloric antrum during LSG is associated with significantly better food tolerance and comparable effect of weight loss up to 6months postoperatively when compared with total antral resection.

Antral Resection versus Antral Preservation during Laparoscopic Sleeve Gastrectomy: Does Outcome Differ?

Background: The surgical technique of sleeve gastrectomy has not been fully standardized and, therefore, there are issues to be solved. Resection of the antrum is one of these debatable issues. Aim:The study aims at assessing the difference in long and short term weight loss between both antral resection laparoscopic sleeve gastrectomy & antral preservation laparoscopic sleeve gastrectomy. Patients and methods: Is a prospective randomized control study including 100 patients with BMI exceeding 35, fifty of them will undergo antral preservation in laparoscopic sleeve gastrectomy (group A), and the other fifty patients will undergo antral resection in laparoscopic sleeve gastrectomy (group B). Results: Weight loss and BMI reduction after 6 months in the antral resection group were more than the antral preservation group with mean weight 92.25 kg in antral resection group compared to 99.46 kg in antral preservation group and mean BMI 34.48 in antral resection group compared to 39.29 in antral preservation group. Also weight loss and BMI reduction after 12 months in the antral resection group were more than the antral preservation group with mean weight 71.60 kg in antral resection group compared to 77.20 kg in antral preservation group and mean BMI 26.41 in antral resection group compared to 30.71 in antral preservation group. Conclusion: Antral resection in LSG safely potentiates the restrictive effect achieved and may result in greater and better maintained weight loss.

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.

The Magnitude of Antral Resection in Laparoscopic Sleeve Gastrectomy and its Relationship to Excess Weight Loss.

The objective of this study was to evaluate the effect of antral resection on weight loss and complications after laparoscopic sleeve gastrectomy (LSG). This was a retrospective study of the prospectively collected data of patients who underwent LSG at Jordan University Hospital from February 2011 to February 2012. Patients were divided into two groups based on antral resection: group A underwent a 6-cm antral resection, and group B underwent a 2-cm antral resection. The percentage of excess weight loss (%EWL) was calculated at 3, 6, 12, and 24 months postoperatively. One hundred and ten patients were included in the study, all of whom completed at least 24 months of follow-up (mean follow-up, 33 months). Their mean body mass index was 46.1 ± 7.9 kg/m(2). In group A, the mean %EWL was 38.1 ± 14.1, 54.9 ± 19.9, 65.6 ± 22.8, and 66.8 ± 28.4% at 3, 6, 12, and 24 months, respectively. However, in group B, the mean %EWL was 42.1 ± 13.4, 63.8 ± 19.8, 80.0 ± 22.1, and 81.5 ± 22.9% at 3, 6, 12, and 24 months, respectively. Patients in group B experienced statistically significant greater weight loss than patients in group A. Statistically significant greater weight regain was seen in group A. Group A had a higher incidence of reflux symptoms (six patients; 11%) than group B (four patients; 7.1%). Radical antral resection in association with LSG safely potentiates the restrictive effect achieved and may result in greater and better maintained weight loss.

Impact of extent of antral resection on surgical outcomes of sleeve gastrectomy for morbid obesity (a prospective randomized study).

Laparoscopic sleeve gastrectomy (LSG) is a surgical technique that treats morbid obesity. Consecutive patients with morbid obesity treated by LSG at our department were evaluated. Patients enrolled in the study were randomized into group I (LSG begins the division 2 cm from the pylorus) and group II (LSG begins the division 6 cm from the pylorus). The primary outcome measure was the percent of excess weight loss (% EWL); secondary outcomes included postoperative morbidity and mortality and improvement of comorbidity. One hundred five patients (79 (75.2 %) were females) were randomized into two groups of (GI) 52 patients and (GII) 53 patients. In group I, the mean % EWL was 51.8 ± 13.9, 63.8 ± 16.1 and 71.8 ± 12; however, in group II, the mean % EWL was 38.3 ± 10.9, 51.9 ± 13.6 and 61 ± 11.1 at 6, 12, and 24 months, respectively (P = 0.0001, 0.0001, 0.003). There was weight regain after 2 years in five patients in group II and only one patient in group I (P = 0.09). There was no significant difference between both group as regards gastric leakage, vomiting or GER. There was significant improvement in comorbidity after LSG in both groups, but no significant difference between them. Hospital mortality occurred in group II in one case as a result of gastric leakage. LSG is a safe and effective procedure with good short-term outcome. Increasing the size of the resected antrum is associated with better weight loss without increasing the rate of complications significantly.

Dilated Upper Sleeve Can be Associated with Severe Postoperative Gastroesophageal Dysmotility and Reflux

Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure, and it can be done as an isolated LSG or in conjunction with biliopancreatic diversion bypass/duodenal switch (laparoscopic duodenal switch; LDS). Gastroesophageal reflux after LSG has been described, but the mechanism is unknown and the treatment in the severest cases has not been discussed. We describe a cohort of patients who have underwent an LSG or LDS, and have suffered from a severe postoperative gastroesophageal motility disorder and/or reflux, report on their treatment, and discuss possible underlying mechanisms. Seven hundred and six patients underwent an LSG by two of the authors (AK, AB). Sixty nine patients underwent laparoscopic sleeve gastrectomy in Hadassah Medical Center, Jerusalem, Israel (January, 2006 and December 2008; 55 isolated LSG, 14 with LDS), and 637 (212 isolated LSG, 425 LDS) in Clinica San Jorge and Alcoy Hospital in Alcoy, Spain, (January 2002 and November 2008). Of them, eight patients who has suffered from a gastroesophageal dysmotility and reflux disease postoperatively and needed a specific treatment besides regular proton pump inhibitors (PPIs) were identified (1.1%). A combination of dilated upper part of the sleeve with a relative narrowing of the midstomach, without complete obstruction, was common to all eight patients who suffered from a severe gastroesophageal dysmotility and reflux. The sleeve volume, the bougie size, and the starting point of the antral resection do not seem to have an effect in this complication. Operative treatment was needed in only one case out of eight; in the rest of the patients, medical modalities were successful. More knowledge is required to understand the underlying mechanisms.