Expected Values of Esophageal Transit and Gastric Emptying Scintigraphy Post-uncomplicated Sleeve Gastrectomy

The role of gastric electrical stimulation in postsurgical gastroparesis: a retrospective analysis from 2 centers

BACKGROUND

Postsurgical gastroparesis, resulting from surgical interventions on the stomach or vagal nerve injury, poses significant clinical challenges with patients presenting symptoms such as nausea, vomiting, and abdominal pain. Although gastric electrical stimulation (GES) offers potential relief, its efficacy in refractory postsurgical gastroparesis requires further examination. This study evaluated the clinical response to GES in patients with refractory postsurgical gastroparesis.

METHODS

A retrospective study was conducted across 2 study sites, involving 185 patients with drug-refractory postsurgical gastroparesis who underwent both temporary and permanent GES placements. Patients were categorized based on their surgical history: bariatric surgery, Nissen fundoplication, and others. The impact of GES was evaluated using Food and Drug Administration-compliant patient-reported outcomes scores and other relevant clinical metrics at baseline, after temporary GES placement, and 6 months after permanent GES placement. All 3 groups were also analyzed by the symptom improved group vs the unimproved group at baseline and 6 months after GES placement.

RESULTS

After GES implantation, all patient groups significantly improved upper gastrointestinal symptoms. The bariatric surgery group and Nissen fundoplication group specifically identified anorexia as the most severe symptom after GES after temporary GES placement among 3 groups (2.5 [0.4-3.5] and 1.5 [0.0-2.5], respectively). Nissen fundoplication patients had the highest score of anorexia among the 3 groups 6 months after GES (3.0 [2.0-3.5], P = .018). Despite these improvements, GES did not enhance gastric emptying test results. Symptomatic improvements were notably significant in patients who initially reported higher symptom severity than those who did not.

CONCLUSION

GES shows promise in alleviating symptoms of refractory postsurgical gastroparesis, particularly in those with severe initial symptoms. However, its impact on gastric emptying remains inconclusive. Further research is needed to establish GES as a standard treatment for postsurgical gastroparesis.

Modified One Anastomosis Gastric Bypass Following Sleeve Gastrectomy for Severe Reflux and Delayed Gastric Emptying: A Prospective Trial with Clinical and Physiological Outcome Measures

BACKGROUND

Gastro-esophageal reflux (GORD) following sleeve gastrectomy (SG) is a central challenge, and precise indications for revisional surgery or the physiology have not been precisely defined. We aimed to determine whether OAGB performed for reflux post-SG (1) accelerates gastric emptying half-time, (2) reduces the frequency and severity of reflux events, and (3) improves reflux symptoms.

METHODS

We undertook a prospective trial (ACTRN12616001089426). There were 22 participants who underwent measurement before and after revisional surgery with 29 optimal SG (patients with optimal outcome from their primary surgery) as controls. All participants underwent a protocolized nuclear scintigraphy, 24-h pH monitoring, and gastroscopy and completed objective questionnaires.

RESULTS

Trial patients were 90.9% female, age 44.4 years. Conversion from SG to OAGB was at a median of 45.2 ± 19.6 months. Scintigraphy showed an increased rate of gastric emptying post-OAGB 34 (IQR 14) vs 24 (IQR 10.3) min, p-value 0.008, with decreased number of reflux events post-prandially (39 (IQR 13) vs 26 (IQR 7), p-value 0.001). This data correlated with the pH analysis; total acid events substantially reduced post-OAGB 58.5 (IQR 88) vs 12 (IQR 9.4) events, p-value 0.017. Endoscopic findings indicated a reduction in incidence of bile stasis 72.7% vs 40.9% post-OAGB, p-value < 0.00010. Post-OAGB, patients experienced less frequent regurgitation (12 ± 4.1 vs. 5.5 ± 3, p-value 0.012) and reflux (37.1 ± 15.7 vs. 16.8 ± 12.6, p-value 0.003).

CONCLUSIONS

We found OAGB is an effective treatment for reflux associated with delayed gastric emptying post-SG. The likely mechanisms is by, an increase in the rate of gastric clearance and reduced reflux events and overall esophageal acid exposure. This suggests that some forms of post-SG reflux are driven by slower emptying of the residual stomach and are amenable to treatment with drainage above the incisura.

Changes in Oesophageal Transit, Macro-Reflux Events, and Gastric Emptying Correlate with Improvements in Gastro-Intestinal Symptoms and Food Tolerance Early Post Sleeve Gastrectomy

PURPOSE

There are significant alterations in gastro-intestinal function, food tolerance, and symptoms following sleeve gastrectomy (SG). These substantially change over the first year, but it is unclear what the underlying physiological basis for these changes is. We examined changes in oesophageal transit and gastric emptying and how these correlate with changes in gastro-intestinal symptoms and food tolerance.

MATERIAL AND METHODS

Post-SG patients undertook protocolised nuclear scintigraphy imaging along with a clinical questionnaire at 6 weeks, 6 months, and 12 months.

RESULTS

Thirteen patients were studied: mean age (44.8 ± 8.5 years), 76.9% females, pre-operative BMI (46.9 ± 6.7 kg/m2). Post-operative %TWL was 11.9 ± 5.1% (6 weeks) and 32.2 ± 10.1% (12 months), p-value < 0.0001. There was a substantial increase of meal within the proximal stomach; 22.3% (IQR 12%) (6 weeks) vs. 34.2% (IQR 19.7%) (12 months), p = 0.038. Hyper-accelerated transit into the small bowel decreased from 6 weeks 49.6% (IQR 10.8%) to 42.7% (IQR 20.5%) 12 months, p = 0.022. Gastric emptying half-time increased from 6 weeks 19 (IQR 8.5) to 12 months 27 (IQR 11.5) min, p = 0.027. The incidence of deglutitive reflux of semi-solids decreased over time; 46.2% (6 weeks) vs. 18.2% (12 months), p-value < 0.0001. Reflux score of 10.6 ± 7.6 at 6 weeks vs. 3.5 ± 4.4 at 12 months, (p = 0.049) and regurgitation score of 9.9 ± 3.3 at 6 weeks vs. 6.5 ± 1.7, p = 0.021 significantly reduced.

CONCLUSIONS

These data demonstrate that there is an increase in the capacity of the proximal gastric sleeve to accommodate substrate over the first year. Gastric emptying remains rapid but reduce over time, correlating with improved food tolerance and reduced reflux symptoms. This is likely the physiological basis for the changes in symptoms and food tolerance observed early post-SG.

Unveiling the effects of key factors in enhancing gastroesophageal reflux: A fluid-structure analysis before and after laparoscopic sleeve gastrectomy

BACKGROUND AND OBJECTIVES

Gastro-oesophageal reflux disease (GERD) consists in the passage of gastric acid content from the stomach to the oesophagus, causing burns and deteriorating the quality of life. Laparoscopic Sleeve Gastrectomy (LSG) could induce de novo GERD and worsen pre-existing GERD because of the higher gastric pressurisation, reduction of stomach volume and a wider His-angle. In the proposed work, various computational gastric 2D models were developed to understand the effects of variables such as the His-angle, the antral dimension, and the bolus viscosity on the reflux increase.

METHODS

Fluid-Structure Interaction (FSI) computational models which couple the solid mechanics of the gastric wall, and the fluid domain of the bolus, have been developed to shed light on biomechanical aspects of GERD after LSG. A closure was imposed to the lower oesophageal sphincter (LES) mimicking what happens physiologically after food intake.

RESULTS

Results showed that the configuration prone to higher reflux flow was the post-surgical 65° model with a staple line starting directly from the pylorus without antral preservation, for all considered viscosities. Increasing viscosity, reflux flow decreased. Post-surgical refluxes were higher than pre-ones and decreased with increasing antrum preservation.

CONCLUSIONS

These results could be a starting point for analysis of anatomical features, bariatric surgery and GERD occurrence. Further studies based on 3D geometries need to be performed.

Delayed Gastric Emptying After Sleeve Gastrectomy Is Associated with Poor Weight Loss

Background

Intermediate to long-term weight regain is a major challenge following sleeve gastrectomy (SG). Physiological changes that mediate the extent of weight loss remain unclear. We aimed to determine if there were specific esophago-gastric transit and emptying alterations associated with weight regain.

Material and Methods

Participants greater than 12 months post-SG were categorized into optimal (n = 29) and poor weight loss (PWL) (n = 72). All patients underwent a liquid contrast barium swallow demonstrating normal post-surgical anatomy and a protocolized nuclear scintigraphy designed specifically to characterize gastric emptying following SG.

Results

The %total weight loss in the optimal group was 26.2 ± 10.5 vs. 14.3 ± 8.8% in the PWL group (p = 0.001). Scintigraphy showed PWL had relatively increased gastric emptying half-time (GE 1/2t) 35 (IQR 23) min vs 19 (IQR 5.5) min (p = 0.001). The multivariate regressions delineated GE 1/2t as the best diagnostic measure for PWL (OR 1.16; CI 1.04–1.29, p-value 0.021). The probability of PWL increased by 16% for every 1-min increase above 21 min of GE 1/2t. A threshold of 21 min was found to have 88% sensitivity and 69% specificity predicting poor weight loss.

Conclusion

Gastric emptying half-times greater than 21 min appear to reliably correlate with poor weight loss following SG. Additionally, further elevations above 21 min in emptying half-time increase the risk of poor weight loss. We have shown nuclear scintigraphy represents a simple and accurate diagnostic tool in patients who experience poor weight loss after SG, provided substantially altered reporting references in interpreting nuclear scintigraphy are applied.

Graphical abstract

Delayed Gastric Emptying After Sleeve Gastrectomy Is Associated with Poor Weight Loss

Background

Intermediate to long-term weight regain is a major challenge following sleeve gastrectomy (SG). Physiological changes that mediate the extent of weight loss remain unclear. We aimed to determine if there were specific esophago-gastric transit and emptying alterations associated with weight regain.

Material and Methods

Participants greater than 12 months post-SG were categorized into optimal (n = 29) and poor weight loss (PWL) (n = 72). All patients underwent a liquid contrast barium swallow demonstrating normal post-surgical anatomy and a protocolized nuclear scintigraphy designed specifically to characterize gastric emptying following SG.

Results

The %total weight loss in the optimal group was 26.2 ± 10.5 vs. 14.3 ± 8.8% in the PWL group (p = 0.001). Scintigraphy showed PWL had relatively increased gastric emptying half-time (GE ^1/2t) 35 (IQR 23) min vs 19 (IQR 5.5) min (p = 0.001). The multivariate regressions delineated GE ^1/2t as the best diagnostic measure for PWL (OR 1.16; CI 1.04–1.29, p-value 0.021). The probability of PWL increased by 16% for every 1-min increase above 21 min of GE ^1/2t. A threshold of 21 min was found to have 88% sensitivity and 69% specificity predicting poor weight loss.

Conclusion

Gastric emptying half-times greater than 21 min appear to reliably correlate with poor weight loss following SG. Additionally, further elevations above 21 min in emptying half-time increase the risk of poor weight loss. We have shown nuclear scintigraphy represents a simple and accurate diagnostic tool in patients who experience poor weight loss after SG, provided substantially altered reporting references in interpreting nuclear scintigraphy are applied.

Graphical abstract

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