3D Volumetry and its Correlation Between Postoperative Gastric Volume and Excess Weight Loss After Sleeve Gastrectomy

Applications of gastric peroral endoscopic myotomy in the treatment of upper gastrointestinal tract disease

Gastric peroral endoscopic myotomy (G-POME) is an emerging minimally invasive endoscopic technique involving the establishment of a submucosal tunnel around the pyloric sphincter. In 2013, Khashab et al used G-POME for the first time in the treatment of gastroparesis with enhanced therapeutic efficacy, providing a new direction for the treatment of gastroparesis. With the recent and rapid development of G-POME therapy technology, progress has been made in the treatment of gastroparesis and other upper digestive tract diseases, such as congenital hypertrophic pyloric stenosis and gastric sleeve stricture, with G-POME. This article reviews the research progress and future prospects of G-POME for the treatment of upper digestive tract gastrointestinal diseases.

Computed tomography-based gastric volumetry for morbid obesity to assess weight loss and fatty liver change

BACKGROUND/PURPOSE

Laparoscopic sleeve gastrectomy (LSG) is an effective treatment for patients with morbid obesity, but the optimal gastric volume (GV) for resection remains unclear. Accordingly, we aimed to determine the optimal percentage of excised stomach that could engender significant weight loss and improve fatty liver.

METHODS

This prospective study included 63 patients. Computed tomography (CT) scans were performed before and 1 year after LSG to evaluate the gastric lumen (GL) and GV. Specifically, the stomach was distended with effervescent powder, following water-contrast mixture (20:1) and assessed by three-dimensional reconstruction. The correlations of reduced gastric lumen/volume (RGL/RGV) with total body weight (BW) loss and liver-spleen density ratio (LSDR) changes were analyzed, and optimal RGL/RGV associated with significant BW and fatty liver changes were determined.

RESULTS

We noted a positive correlation between the percentage of RGV/RGL (%RGV/%RGL) and percentage of total weight loss (%TWL; r = 0.359, p = 0.004 and r = 0.271, p = 0.032). Furthermore, a %RGL value of >78.2% and %RGV value of >75.3% were associated with more significant BW loss than did limited excision (both p < 0.01). On the other hand, LSDR values increased significantly after LSG, corresponding to the improvement of fatty liver disease at %RGL and %RGV values of >59.1% and >56.4% (both p < 0.01), respectively.

CONCLUSION

%RGV and %RGL were determined to be factors affecting LSG outcomes. LSG engendered significantly more BW loss when %RGV was >75.3% and resulted in fatty liver disease improvement when %RGV was >56.4%.

Posterior fixation of gastric tube with fibrin sealant in laparoscopic sleeve gastrectomy: a promising method to prevent revision surgeries

BACKGROUND

We aim to assess the effects of gastric posterior fixation with fibrin sealant in laparoscopic sleeve gastrectomy in aspects of 12th-month body mass index and gastric volume.

METHODS

The patients who underwent laparoscopic sleeve gastrectomy between January 2019 and February 2021 were divided into two groups preoperatively. The first 75 patients were appointed to the posterior fixation group, and the second 75 were to the control group. Changes in gastric volume and body mass index were assessed in the postoperative 12th month.

RESULTS

There were 110 patients in the final analysis. Fifty-four patients had posterior fixation, and 56 had only laparoscopic sleeve gastrectomy. The posterior fixation group was superior in terms of total weight loss rate (39.1% vs. 34.5%, p<0.001) and less gastric volume increase rate (39.8% vs. 164.7%, p<0.001) in the postoperative 12th month.

CONCLUSION

Our study suggests that posterior fixation with fibrin sealant in laparoscopic sleeve gastrectomy is a promising method for preventing weight regain and creating a need for revision surgery.

The Evaluation of Gastric Emptying Using Nuclear Scintigraphy Compared to Three-Dimensional Multi-detector Computed Tomography (3D-MDCT) Gastric Volumetry in the Assessment of Poor Weight Loss Following Sleeve Gastrectomy

BACKGROUND

Poor weight loss and weight regain are principal challenges following laparoscopic sleeve gastrectomy (LSG). There is a lack of standardised assessments and diagnostic tests to stratify the status post-LSG and determine whether anatomical or physiological problem exists. We aimed to compare nuclear scintigraphy gastric emptying with CT volumetric analysis of sleeve anatomy and determine the impact of anatomy on physiological function and its correlation with weight loss.

MATERIALS AND METHODS

Patients greater than 12 months post-LSG were categorised into optimal weight loss (OWL) (n = 29) and poor weight loss groups (PWL) (n = 50). All patients underwent a protocolised nuclear scintigraphy and three-dimensional multi-detector computed tomography (3D-MDCT) gastric volumetry imaging.

RESULTS

Post-operative % total weight loss in OWL was 26.2 ± 10.5% vs. 14.2 ± 10.7% in the PWL group (p value < 0.0001). The PWL group had significantly more delayed gastric emptying half-time than OWL (34.1 ± 18.8 vs. 19.5 ± 4.7, p value < 0.0001). Gastric emptying half-time showed statistically significant correlations with weight loss parameters (BMI; r = 0.215, p value 0.048, %EWL; r =  - 0.336, p value 0.002 and %TWL; r =  - 0.379, p value < 0.001). The median gastric volume on 3D-MDCT did not differ between the OWL (246 (IQR 50) ml) and PWL group (262 (IQR 129.5) ml), p value 0.515. Nuclear scintigraphy gastric emptying half-time was the most highly discriminant measure. A threshold of 21.2 min distinguished OWL from PWL patients with 86.4% sensitivity and 68.4% specificity.

CONCLUSION

Nuclear scintigraphy is a potentially highly accurate tool in the functional assessment of sleeve gastrectomy physiology. It appears to perform better as a diagnostic test than volumetric assessment. Gastric volume did not correlate with weight loss outcomes. We have established diagnostic criteria of greater than 21 min to assess sleeve failure, which is linked to suboptimal weight loss outcomes.

Sleeve gastrectomy morphology and long-term weight-loss and gastroesophageal reflux disease outcomes

BACKGROUND

The relationship between sleeve gastrectomy (SG) morphology and long-term weight-loss and gastroesophageal reflux disease (GERD) outcomes is unknown.

METHODS

All patients (n = 268) undergoing SG performed by 3 surgeons at a single academic institution from January 1, 2010 to December 31, 2012 were included. Long-term weight-loss and GERD outcomes were available for 90 patients which were incorporated in analyses. SG morphology was determined from postoperative day 1 upper gastrointestinal series (UGIS) available from 50 patients. Images were independently categorized using previously published methodology as Dumbbell (38%), Lower Pouch (22%), Tubular (26%), or Upper Pouch (14%) by Radiologist and Surgeon. Radiologist categorization was used when disagreement occurred (8%). Univariable analyses were conducted to explore potential associations between SG morphology, weight loss, and GERD outcomes.

RESULTS

Follow-up was 8.2 ± 0.9 years. Population characteristics included age of 45.1 ± 10.8 years, female sex in 83.3%, and hiatal hernia repair (HHR) performed at index SG in 17.8%. Surgeons did not preferentially achieve a specific SG morphology. Changes from preoperative obesity and associated diseases comprised body mass index (BMI) (49.5 ± 7.6 vs. 39.2 ± 9.4 kg/m²; p < 0.0001), diabetes mellitus (30.0 vs. 12.2%; p = 0.0006), hypertension (70.0 vs. 54.4%; p = 0.0028), hyperlipidemia (42.2 vs. 24.2%;p = 0.0017), obstructive sleep apnea (41.1 vs. 15.6%; p < 0.0001), osteoarthritis (48.9 vs. 13.3%; p < 0.0001), back pain (46.5 vs. 28.9%; p = 0.0035), and medications (4.8 ± 3.3 vs. 3.7 ± 3.5; p < 0.0001). Dumbbell SG morphology was associated with lesser reduction in BMI at follow-up (--6.8 ± 7.2 vs. -12.4 ± 8.3 kg/m²; p = 0.0196) while greater BMI change was appreciated with Lower Pouch SG shape (-16.9 ± 9.9 vs. -8.4 ± 6.8 kg/m²; p = 0.0017). GERD was more prevalent at follow-up than baseline (67.8 vs. 47.8%; p < 0.0001). GERD-specific outcomes included de novo (51.1%), persistent (27.9%), worsened (58.1%), and resolved (14.0%) disease. Ten patients underwent reoperation for refractory GERD with SG morphology corresponding to Dumbbell (n = 5) and Upper Pouch (n = 1) for those with available UGIS. Univariable analyses showed that patients with GERD experienced a larger reduction in BMI compared with patients without GERD (-11.8 ± 7.7 vs. -7.0 ± 5.1 kg/m²; p = 0.0007). Patient age, surgeon, morphology category, and whether a HHR was done at index SG were not associated with the presence of any, de novo, or worsened GERD. Female sex was associated with worsened GERD (96.0 vs. 4.0%; p = 0.0455). Type of calibration device, distance from staple line to pylorus, and whether staple line reinforcement was used were not associated with SG morphology classification.

CONCLUSION

This is the first study assessing the impact of SG morphology on long-term weight loss and GERD. Our data suggest an association between SG morphology and long-term weight loss but not with GERD outcomes. Current technical standards may be limited in reproducing the same SG morphology. This information may help guide the technical optimization and standardization of SG. Surgeons did not favor a specific SG morphology (1). Our results signal to a relationship between radiographic assessment of SG morphology and long-term weight-loss outcomes with Dumbbell classification correlated with lesser reduction in BMI (2a) and Lower Pouch morphology associated with superior weight loss (2b). SG, sleeve gastrectomy; BMI, body mass index.

Role of 3D-CT gastric volumetric study in post-sleeve gastrectomy

Background

Gastric pouch volumetry after sleeve gastrectomy reflects successful surgery. We aimed to assess the impact of gastric pouch volume after sleeve gastrectomy on weight loss.

Method

The study was performed for 30 patients (22 females and 8 males) who underwent sleeve gastrectomy. Their ages ranged from 18 to 47 years. All patients underwent (multi-slice CT) MSCT examination at 12 months after surgery with oral administration of effervescent emulsion. Post-processing in multi-planar reconstruction and 3D reconstruction was performed to all cases. Gastric pouch volume was measured and correlated with body weight, body mass index (BMI), % reduction in excess body weight and ∆weight at 1 year.

Results

A significant positive association was found among gastric volume pouch and weight loss (P = 0.04), BMI reduction (P value < 0.0001) and ∆weight (P value = 0.013). A significant inverse association was found among gastric pouch volume and % reduction in excess body weight (P value = 0.013).

Conclusion

MSCT gastric volumetry is the gold standard imaging method for assessment of the gastric pouch volume after sleeve gastrectomy. Significant positive association was found among gastric volume pouch and weight loss, BMI reduction and ∆weight at 1 year, i.e., in spite of large gastric pouch volume at 1 year, there is adequate weight loss, BMI reduction and ∆weight. Yet, significant inverse association was found among gastric pouch volume and % reduction in excess body weight.

Intrathoracic pouch migration in one-anastomosis gastric bypass with and without hiatoplasty: A 3-dimensional-computed tomography volumetry study

BACKGROUND

Currently, 4.8% of bariatric operations worldwide are one-anastomosis gastric bypass (OAGB) procedures. If a hiatal hernia is detected in a preoperative gastroscopy, OAGB can be combined with hiatoplasty. Intrathoracic pouch migration (ITM) is common after bypass procedures because the fundus, a natural abutment, is separated from the pouch.

OBJECTIVE

The aim of this study was to find out whether OAGB or OAGB combined with hiatoplasty carries a higher risk of ITM and, therefore, also gastroesophageal reflux disease (GERD).

SETTING

University hospital.

METHODS

Fifty patients (group 1: 25× primary OAGB; group 2: 25× primary OAGB with hiatoplasty) were included in this study. History of weight, GERD, and quality of life were recorded in patient interviews and pouch volume and ITM were evaluated using 3-dimensional-computed tomography volumetry.

RESULTS

There were no differences in terms of patient characteristics, history of weight, pouch volume, or quality of life between both groups. ITM was found in group 1 in 60% (n = 15) and group 2 in 76% (n = 19) of all patients (P = .152). The ITM mean length was significantly lower in group 1 with .9 ± 1.1 cm than in group 2 with 1.8 ± 1.2 cm (P = .007). Regarding GERD, there was no difference between both groups; nevertheless, significantly more patients with ITM (38.2%; n = 13) had GERD compared with patients without ITM (6.3%; n = 1).

CONCLUSION

In primary OAGB, an additional hiatoplasty was not associated with higher rates of ITM or GERD; nevertheless, the length of ITM was higher after hiatoplasty. If ITM occurs, patients have a risk of developing GERD.

Volumetric Pouch Study After Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is considerably utilized as a bariatric method for treating morbid obesity through the reduction of stomach volume. The present study attempted to assess the volumetric changes of the gastric reservoir 1 year after LSG using multi-slice spiral computed tomography (MSCT) as well as to verify their association with weight loss. The current study is a prospective study of 40 consecutive morbid obese patients managed with laparoscopic sleeve gastrectomy. All patients were referred to abdominal MSCT besides volumetric measurement of the gastric pouch 1 month and 12 months postoperatively after the LSG. There were statistically substantial differences throughout the whole period of follow-up (p value ≤ 0.05) regarding the ratio of excess weight loss, weight loss, and decreased BMI, in addition to the ratio of excess body mass index loss (% EBMIL) after LSG. Substantial elevation of the overall volume of the gastric reservoir (82.9 SD11 and 171.6 SD23.6 ml at 1 and 12 months, respectively) was observed. However, the current findings did not demonstrate any significant association (r = 0.131, p = 0.491) between excess weight loss percentage and the increase in gastric reservoir volume 1 year postoperatively. Sleeve dilatation is a common finding following sleeve gastrectomy (SG) even after conducting a narrow gastric pouch, yet dilatation was not correlated with insufficient weight loss after 1 year postoperatively. Trial registration number: NCT04880902.

Relationship between residual gastric area and weight loss after sleeve gastrectomy: A Cohort study

BACKGROUND

The aim of this study is to evaluate the impact of the actual size and area of the remnant stomach, as measured by Upper gastrointestinal tract radiography, on weight loss after sleeve gastrectomy.

MATERIALS AND METHODS

From May 2017 to December 2019, 56 patients with morbid obesity were admitted to the Department of Medical and Surgical Sciences, University of Foggia and underwent laparoscopic sleeve gastrectomy.

RESULTS

56 patients underwent sleeve gastrectomy with a mean age of 43,5 ± 11 years of which 40 were female. The mean Excess Weight Loss (EWL) at 1 month was 24,09 ± 15,04%, at 6 months was 27,07 ± 19,55% and at 12 months was 69,9 ± 23,7%. The mean Excess Body Mass Index Loss (EBMIL) at 1 month was 23,1 ± 12,5%, at 6 months was 56,6 ± 19,7% and at 12 months was 69,7 ± 23,7%.The EWL % was correlated with the residual stomach area (RSA) at 1 month (r = -0,242 p = 0,072), at 6 months (r = -0,249 p = 0,064) and at 12 months (r = -0,451 p = 0,0005).The EBMIL % was correlated with the RSA at 1 month (r = -0,270; p = 0,043), at 6 months (r = -0,270; p = 0,043) andat 12 months (r = -0,46; p = 0,0004).

CONCLUSION

A greater postoperative EWL % was correlated with a smaller RSA and this resulted in a statistically significant change at 12 months after surgery.

3D CAT Scan and Gastric Volumetry in the Planning of Revisional Bariatric Surgery

Background: The planning of revisional bariatric surgery is a complex process. The availability of accurate anatomical information is especially important for the planning of such challenging surgical procedures, we present our initial experience using three-dimensional-computed tomography (3D-CT) images to preoperatively assess the anatomy of patients before bariatric revisional surgery. Methods: We used 3D reconstructed images of CT scans to assess the anatomy and plan revisional surgery in 144 patients 98 of them had a previous sleeve gastrectomy 41 had a previous gastric by-pass and 4 Vertical banded gastroplasties. An effervescent preparation was used to distend the stomach and the proximal bowel allowing volume estimation. Results: Eleven sleeve patients underwent a re-sleeve gastrectomy and 44 were revised to a "Roux-en-Y" gastric bypass (RYGBP). Forty-two patients with a previous gastric by-pass were revised due to weight regain or other issues and 4 patients with previous vertical banded gastroplasty (VBGP) were revised to RYGBP. 3D-CT scans provided valuable information for the planning of all revisional procedures by offering accurate information about the existing anatomy and measures of the volume of the gastric pouch, the size of the gastro-jejunal anastomosis in gastric by-pass cases, or the volume and shape of the gastric tube in gastric sleeve cases. Conclusion: 3D-CT is a fast, widely available, reliable, and accurate tool to assess the anatomy after bariatric procedures. This noninvasive method can be particularly useful for the evaluation of postbariatric patients with failures, suboptimal results, and complications, and for the planning of revisional surgery.

Correlation Between Preoperative Gastric Volume and Weight Loss After Laparoscopic Sleeve Gastrectomy

Purpose

Long-term studies reported inadequate weight loss or weight regain after laparoscopic sleeve gastrectomy (LSG). This study investigated a possible relationship between preoperative gastric volume (GV) measured by CT volumetry and weight loss one year after LSG.

Methods

This prospective study included 120 patients scheduled for LSG. 3D CT gastric volumetry was done before surgery. The weight loss in the first year was serially recorded. The primary outcome measure was the correlation between preoperative GV and postoperative weight loss after one year. The secondary outcomes were the correlation between preoperative GV and other patients’ characteristics as age and body mass index (BMI).

Results

Weight and BMI decreased significantly up to 12 months. The percentage of excess weight loss (%EWL) at 6 and 12 months was significantly higher than at three months. Preoperative GV was 1021 ± 253, ranging from 397 to 1543 mL. GV was not related to sex, age, weight, height, postoperative weight, and BMI.

Conclusion

Preoperative gastric volume cannot predict weight loss one year after LSG. It is not correlated with age, sex, or preoperative weight, and BMI.

Effect of laparoscopic sleeve gastrectomy on drug pharmacokinetics

INTRODUCTION

Given its feasibility and efficacy, laparoscopic sleeve gastrectomy (LSG) has become a widely accepted bariatric surgery for patients with clinically diagnosed severe obesity. LSG induces anatomical changes and subsequent weight loss which may affect drug pharmacokinetics (PK) and consequently impact dosing regimens. This review aims to examine the effect of LSG on drug PK and identify relevant gastrointestinal physiological alterations.

AREAS COVERED

PubMed, Embase, Scopus, and the Cochrane Library were searched for articles related to drug PK and LSG from inception to July 2021. Moreover, literature concerning postoperative physiological conditions in the gastrointestinal tract, such as gastric pH, gastric emptying, and small bowel transit time, etc., which may affect the PK profile of drug products was also reviewed.

EXPERT OPINION

Although LSG is classified as having restrictive property without malabsorptive bypass, postoperative changes in gastrointestinal physiology and subsequent weight loss may also lead to increased, decreased or unaltered drug exposure levels. General monitoring on drug efficacy or safety using biomarkers is proposed. In addition, therapeutic drug monitoring for those drugs when it is applicable and available is recommended to ensure efficient drug dosing and avoid adverse effects. Further research into many individual drugs are warranted.

Endoscopic Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review

Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.

Correlation of Gastric Volume and Weight Loss 5 Years Following Sleeve Gastrectomy

INTRODUCTION

The volume of the gastric reservoir (VGR) after sleeve gastrectomy influences weight loss in the short-term, but long-term results are scarce. The aim was to analyze the correlation between the VGR and weight loss at 5 years of follow-up.

METHODS

It is a prospective observational study of 50 patients undergoing sleeve gastrectomy (SG) from February 2009 to December 2013. An upper gastrointestinal series was performed at 1 month and at 1 and 5 years after surgery. A composite formula was used for VGR estimation. Weight loss-related data included the following: body mass index (BMI), percentage of excess weight loss (%EWL), and percentage of excess BMI loss (%EBMIL) at 1 month and at 1 and 5 years. Uni- and multivariate analyses were carried out to determine other factors that might influence long-term weight loss results.

RESULTS

The %EWL at 1 year was 74.5(63.8-86) vs. 55.5(47-74.3) at 5 years (p < 0.001). The VGR 1 month after surgery was 114.9 (90.5-168.3) mL. The VGR increased from 216.7 (155.1-278.6) to 367.5 (273-560.3) mL (p < 0.001) at 1 and 5 years. Although a significant inverse correlation was observed between VGR and BMI, %EWL, and %EBMIL at 1 year, it disappeared at 5 years. In the multivariate analysis, the main factor to predict worse weight results at 5 years was a pre-surgical BMI ≥ 50 kg/m².

CONCLUSION

The VGR increased progressively during the study period. Although an inverse relationship between VGR and weight was found at 1 year, this correlation did not remain at 5 years. A preoperative BMI ≥ 50 kg/m² is the main predictive factor of poor weight outcomes.

Intrathoracic Migration of Gastric Sleeve Affects Weight Loss as well as GERD-an Analysis of Remnant Gastric Morphology for 100 Patients at One Year After Laparoscopic Sleeve Gastrectomy

PURPOSE

Laparoscopic sleeve gastrectomy (SG) is now frequently performed as a definitive bariatric procedure. The aim of the study was to evaluate the detailed morphology of remnant stomachs after SG with respect to volume and sleeve migration.

MATERIALS AND METHODS

We performed a review of prospectively collected data on patients that completed a 12-month postop examination, which included CT volumetry of the sleeve, and a questionnaire that addressed postop food tolerance. CT volumetry study included total sleeve volume (TSV), tube volume (TV), antral volume (AV), tube/antral volume ratio (TAVR), and the presence of intrathoracic sleeve migration (ITSM).

RESULTS

One hundred patients were included in this study. Mean %TWL (total weight loss) at 12 months postop was 31.1% (14.3~55.5), and mean TSV, TV, AV, and TAVR were 188.3 ± 67.3 ml, 81.3 ± 38.5 ml. 107.0 ± 45.1 ml, and 0.846 ± 0.514 respectively. TSV was not correlated significantly with %TWL at 12 months postop (r=-0.140, p=0.164). Thirty patients (30/100, 30%) showed ITSM. Patients with ITSM had a significantly lower mean GER score (5.9 ± 2.3 vs. 7.5±1.9, p=0.001), and a higher proportion showed suboptimal weight loss (43.3% vs. 15.7%, p=0.003).

CONCLUSIONS

Mean TSV was not found to be significantly correlated with %TWL at 12 months postop. The presence of ITSM indicated more frequent GER symptoms and a higher probability of suboptimal weight loss.

Laparoscopic Banded Sleeve Gastrectomy: Single-Center Experience with a Four-Year Follow-Up

Introduction: Laparoscopic sleeve gastrectomy (LSG) is now the most common bariatric procedure to treat morbidly obese patients. The main concern of LSG lies in the long-term weight regain, which is reported to happen in up to 75.6% of patients after 6 years. In this study, we report our overall experience with Laparoscopic Banded Sleeve Gastrectomy (LBSG) using the MiniMizer^® over a 6-year period. Materials and Methods: We performed a retrospective review of data from a prospectively collected database. All patients submitted to primary LBSG were examined. Patients were submitted to LBSG between February 2014 and January 2020. Collected data included demographic factors, preoperative body mass index (BMI), operative time, surgical complications, and clinical outcomes. Results: Two hundred nine patients were submitted to primary LBSG in the study period. They were 136 females (65%) and 73 males (35%) with a median age of 43.0 years (range, 18-65 years). Median preoperative BMI was 48.4 kg/m² (range, 36.2-65.5 kg/m²). Median operative time was 72.0 minutes (range, 40-142 minutes). Median time for ring placement was 8.0 minutes. Median postoperative hospital stay was 2.8 days. Seven major complications occurred in the postoperative period (3.3%): five gastric leaks (2.3%) and two major bleedings (0.9%). There was no postoperative mortality in the 209 patients. Long-term major complications occurred in 2 patients (0.9%). Median follow-up was 49.2 months (range, 2-72 months). Median postoperative BMI was 29.6 kg/m² (range, 22-42 kg/m²). Median %excess weight loss (%EWL) at 1 year after surgery was 52.0%. Median %EWL at last follow-up visit was 64.0%. Conclusion: LBSG is as safe as standard LSG with excellent results in terms of postoperative morbidity and weight loss outcomes. Whether this procedure may result superior to standard LSG in the long-term period needs to be evaluated in randomized trials. Clinical Study Registration Number: NCT04354532.

Morphologic Study of Gastric Sleeves by CT Volumetry at One Year after Laparoscopic Sleeve Gastrectomy

PURPOSE

Laparoscopic sleeve gastrectomy (SG) is now frequently performed as a definitive bariatric procedure. The aim of the study was to evaluate the detailed morphology of remnant stomachs after SG with respect to volume and sleeve migration.

MATERIALS AND METHODS

We performed a retrospective review of prospectively collected data on patients that completed a 12-month postop examination, which included CT volumetry of sleeve, and a questionnaire that addressed postop food tolerance. CT volumetry study included total sleeve volume (TSV), tube volume (TV), antral volume (AV), tube/antral volume ratio (TAVR), and the presence of intrathoracic sleeve migration (ITSM).

RESULTS

Fifty-five patients were included in this retrospective study. Mean %TWL (% total weight loss) at 12 months postop was 32.8% (14.3-55.5), and mean TSV, TV, AV, and TAVR were 166.6±63.3 ml, 68.9±35.4 ml, 97.7±42.9 ml, and 0.8±0.6 respectively. TSV was not correlated significantly with %TWL at 12 months postop (r=-0.069, P=0.619). Fourteen patients (14/55, 25.5%) showed ITSM by CT. Patients with ITSM had a significantly lower mean GER score (5.1±2.0 vs. 7.3±2.0, P=0.001), a lower total food tolerance score (21.6±3.8 vs. 24.4±4.6, P=0.048), and a higher proportion showed suboptimal weight loss (35.7% vs. 9.8%, P=0.023).

CONCLUSION

Mean TSV was not found to be significantly correlated with %TWL at 12 months postop. Patients with suboptimal weight loss had higher mean TAVR, and the presence of ITSM indicated more frequent GER symptoms, lower food tolerance, and a higher probability of suboptimal weight loss.

Correlation of weight loss with residual gastric volume on computerized tomography in patients undergoing sleeve gastrectomy: A systematic review

Laparoscopic Sleeve gastrectomy (LSG) is the most commonly performed bariatric surgical procedure worldwide. There is wide variation however in post-operative weight loss on long term follow-up, and residual gastric volume (RGV) is believed to be an important variable. Multiple studies have correlated RGV as assessed by Computerized Tomography volumetry with excess weight loss (EWL%) following LSG, but definite consensus is lacking. This article systematically reviews the published studies in English literature to ascertain whether any correlation exists between the RGV and EWL% following LSG. Ten studies were included in this review, and significant differences were noted in the technique of RGV assessment, and timing of RGV and EWL% assessment. Five studies found a statistically significant correlation between the RGV and EWL%. One study found a correlation which did not reach statistical significance. Two additional studies reported that the resected volume rather than RGV correlated with the EWL%. Meta-analysis of studies reporting correlation between RGV and EWL% showed that up to 26.3% (95% CI: 5.1%-56.1%) of variability in EWL% can be explained by variations in RGV. A lower RGV is likely to result in a better post-operative weight loss following LSG. There is need for standardization of technique and timing of RGV assessment.

Relation of Gastric Volume With Weight Loss After Sleeve Gastrectomy: Results of a Prospective Analysis

BACKGROUND

Postoperative sleeve volume (SV) is a key factor in evaluating the results of laparoscopic sleeve gastrectomy (LSG). An objective measurement of SV was obtained with 3-dimensional computed tomographic (3DCT) reconstruction. Several studies have compared SV with percent excess weight loss (%EWL), identifying an inverse relationship. We hypothesized that gastric capacity is one of the factors responsible for weight loss after LSG.

OBJECTIVES

Outcomes of the study were the analysis of the inverse correlation between SV and weight loss (%EWL and body mass index) at the 12-month follow-up, and evaluation of SV in the group with %EWL >50%. In addition, the failure rate was quantified in the SV >180 mL group.

MATERIALS AND METHODS

This is a prospective study with the collection of data. All patients who received LSG from January to December 2017 were evaluated. Computed tomography was performed on the upper abdomen at 12 months postoperatively to measure the SV using a standardized technique involving gastric distension.

RESULTS

A total of 42 patients were considered for 3DCT evaluation at the 12-month follow-up. A significant linear inverse relation was reported between SV and %EWL (P<0.05); a similar trend, without significant results, was reported for body mass index loss. The entire cohort was subdivided according to %EWL. A %EWL<50% presented a significantly higher mean SV (P<0.01) than %EWL >50%. SV >180 mL was powerful in predicting abnormal gastric distension. Over this value, %EWL was lower than that in the remaining group (P<0.05, 31.9% vs. 51.8%).

CONCLUSIONS

Our results confirmed a direct relation between SV and %EWL. Objective evaluation of gastric compliance obtained with 3DCT should be used intensively for LSG.

Effects of Laparoscopic Sleeve Gastrectomy on Gastric Structure and Function Documented by Magnetic Resonance Imaging Are Strongly Associated with Post-operative Weight Loss and Quality of Life: a Prospective Study

BACKGROUND

This prospective study applied magnetic resonance imaging (MRI) to assess the effect of laparoscopic sleeve gastrectomy (LSG) on gastric structure and function. The impact of these changes on patient outcomes was analyzed.

METHOD

Obese patients without gastrointestinal symptoms referred for bariatric surgery were recruited prospectively. Pre-operative assessment included (i) high-resolution manometry and pH-impedance monitoring and (ii) magnetic resonance imaging (MRI) measurement of gastric capacity, accommodation, and emptying with the 400 ml liquid Nottingham test meal (NTM). Studies were repeated 6-7 months after LSG. Weight loss and changes in the Gastrointestinal Quality of Life Index (GIQLI) assessed patient outcomes.

RESULTS

From 35 patients screened, 23 (66%) completed the study (17 females, age 36 ± 10 years, BMI 42 ± 5 kg/m2). Mean excess weight loss was 59 ± 18% at follow-up. Total gastric volume (capacity) after the meal was 467 mL (455-585 ml) before and 139 mL (121-185 ml) after LSG (normal reference 534 (419-675) mL), representing a mean 70% reduction (p < 0.0001). Similar findings were present for gastric content volume indicating rapid early-phase gastric emptying (GE) post-LSG. Conversely, late-phase GE was slower post-LSG (2.5 ± 1.0 vs. 1.4 ± 0.6 mL/min; p < 0.0001; (reference 1.5(1.4-4.9) mL/min)). Patients with ≥ 80% reduction in gastric capacity had greater weight loss (p = 0.008), but worse gastrointestinal outcomes (p = 0.023).

CONCLUSIONS

MRI studies quantified the marked reduction in gastric capacity after LSG. The reduction in capacity was associated with rapid early- but slow late-phase GE after surgery. These changes were associated with weight loss; however, reductions in gastric capacity ≥ 80% were linked to increased acid reflux and impacted on gastrointestinal quality of life.

Endoscopic intragastric balloon: a gimmick or a viable option for obesity?

Worldwide, the prevalence of obesity has doubled since 1980 in 70 countries. More than one in three adults now suffer from overweight or obesity. Health problems related to obesity include orthopedic problems, psychiatric conditions, metabolic and cardiovascular diseases, and of increasing concern, cancer. Thus, obesity has an enormous impact on the individual’s wellbeing as well as on society’s workforce and health care expenses. Medical efforts are ongoing to find safe and effective treatment options for obesity and its metabolic implications. At present, available treatment options include lifestyle interventions, pharmacotherapy, endoscopic applications, and bariatric surgery. Within the range of endoscopic treatment options, the intragastric balloon is the most widely used device. The idea is simple: the gastric volume is reduced by a balloon that is in most cases implanted by an endoscopic procedure similar to a gastroscopy. During the past decades, different models have been developed, which we will briefly introduce in this review. We aim at reviewing the pathophysiology underlying the effect of endoscopic intragastric balloon on weight loss and metabolic changes. We will assess expected short-term and long-term benefits for the patient, and we will discuss common side effects as well as rare complications. We will compare endoscopic intragastric balloon to conservative treatment options with or without pharmacological support on the one hand and to the spectrum of bariatric surgery on the other hand. In most patients, obesity must be considered a chronic disease that requires a lifelong treatment concept. In view of current treatment options for obesity, we will discuss whether endoscopic intragastric balloon is a viable treatment option, and who may be the right patient to benefit from it.

Impact of Resected Gastric Volume on Postoperative Weight Loss after Laparoscopic Sleeve Gastrectomy

Among the bariatric surgery community, it has recently emerged the idea of a possible association between resected gastric volume (RGV) and weight loss after laparoscopic sleeve gastrectomy (LSG). If the size of the sleeve depends on the bougie caliber, the resected volume of the stomach remains something which is not possible to standardize. The aim of the study was to investigate a possible relationship between RGV and weight loss after LSG. We developed a mathematical method to calculate the RGV, based on the specimen size removed during LSG. Ninety-one patients (63 females and 28 males) affected by morbid obesity were included in the study. They underwent LSG between 2014 and 2016. Mean preoperative BMI was 45 ± 6.4. At 1 year after LSG, the mean BMI was 30 ± 5.3 and the EWL% was 65 ± 20.2. The statistical analysis of RGV, BMI, and EWL% at 1-year follow-up did not find any correlation between the volume of stomach removed and the weight loss after LSG. Further studies in the future should clarify the potential role of RGV during LSG. This trial is registered with ClinicalTrials.gov NCT03938025.