|Year : 2022 | Volume
| Issue : 1 | Page : 24-29
Gastric remnant shape following laparoscopic sleeve gastrectomy correlates with weight loss: A retrospective cohort study
Dale Jobson1, Julia Freckelton2, Melanie Seale3, Lynn Chong1, Nicole N Winter1, Matthew Read4, Salena Ward1, Michael W Hii4
1 Department of Upper Gastrointestinal and Hepatobiliary Surgery, St Vincent's Hospital, Melbourne, Australia
2 Department of Upper Gastrointestinal and Hepatobiliary Surgery, St Vincent's Hospital; School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
3 Department of Radiology, St Vincent's Hospital, Melbourne, Australia
4 Department of Upper Gastrointestinal and Hepatobiliary Surgery, St Vincent's Hospital; Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Australia
|Date of Submission||11-Jan-2022|
|Date of Acceptance||21-Feb-2022|
|Date of Web Publication||01-Apr-2022|
Dr. Dale Jobson
St Vincents Hospital Melbourne 41 Victoria Pde, Fitzroy, Victoria 3065
Source of Support: None, Conflict of Interest: None
Background: Laparoscopic sleeve gastrectomy (LSG) is a safe and effective bariatric surgical procedure. Sleeve configuration is believed to be an important outcome of good operative technique, yet the relationship of sleeve shape to clinical outcomes including weight loss and postoperative symptoms is not clearly defined. This study aims to identify whether gastric remnant anatomical shape is associated with short-term postoperative weight loss or symptoms of reflux, regurgitation, or dysphagia. Methods: 207 LSG patients were identified from a prospective, multicentre unit database who had surgery between June 2015 and June 2019. Routine postoperative upper gastrointestinal gastrograffin contrast studies were performed between postoperative days one to five and analyzed using a standardized protocol. Gastric remnant shape was classified as either tubular, proximal pouch or distal pouch consistent with previous studies. ANOVA Kruskal − Wallis and Mann − Whitney U-tests were performed to determine the effect of gastric remnant anatomy on weight loss. Descriptive statistics examined the symptoms of reflux, regurgitation, and dysphagia. Results: Gastric remnant anatomy was classified as tubular in 159/207 (78%), proximal pouch in 15/207 (7%), and distal pouch in 33/207 (16%). Patients with a tubular shape had a significantly greater reduction in median body mass index at 12 months postoperatively compared to those with a proximal pouch (11.3 kg/m2 vs. 10.2 kg/m2, P = 0.01). There was no relationship identified between gastric remnant shape and postoperative reflux, regurgitation, or dysphagia. Conclusion: A tubular-shaped gastric remnant is associated with increased weight loss. This suggests that tubular shape should be considered the desired LSG shape for greatest weight loss.
Keywords: Anatomy, gastric remnant, laparoscopic sleeve gastrectomy, reflux, weight loss
|How to cite this article:|
Jobson D, Freckelton J, Seale M, Chong L, Winter NN, Read M, Ward S, Hii MW. Gastric remnant shape following laparoscopic sleeve gastrectomy correlates with weight loss: A retrospective cohort study. J Bariatr Surg 2022;1:24-9
|How to cite this URL:|
Jobson D, Freckelton J, Seale M, Chong L, Winter NN, Read M, Ward S, Hii MW. Gastric remnant shape following laparoscopic sleeve gastrectomy correlates with weight loss: A retrospective cohort study. J Bariatr Surg [serial online] 2022 [cited 2022 Oct 2];1:24-9. Available from: http://www.jbsonline.org/text.asp?2022/1/1/24/342522
| Introduction|| |
Bariatric surgery has been proven to be effective in achieving sustained weight loss, a reduction in obesity-associated disease and improved health related quality of life. Laparoscopic sleeve gastrectomy (LSG) is now the most common bariatric procedure performed worldwide, with significant growth in the Asian region. It involves the removal of a large portion of the stomach along the greater curvature resulting in a reduction of gastric volume and alteration of shape.
LSG is considered a restrictive bariatric procedure; however, the exact mechanisms of action which produce weight loss are multiple and incompletely defined. Important proposed actions include, but are not limited to, reduced food intake assisted by the reduction in gastric volume,, and neurohormonal changes decreasing appetite and causing early satiety.
The stomach remaining after LSG, called the gastric remnant, can be anatomically characterized using upper gastrointestinal (UGI) gastrograffin contrast studies or volumetric computed tomography imaging.,,,, These can be performed with or without gastric distention. Three post-LSG gastric remnant shapes using UGI contrast studies have been previously described; tubular, superior pouch and inferior pouch. Some studies also defined a forth shape, dumbbell, a combination of a superior and inferior pouch.,
A potential adverse effect of LSG is the development of gastroesophageal reflux disease (GORD) which, in some cases, can be severe., The development of GORD postoperatively is likely due to the disruption of lower esophageal spincter fibres, increased intraluminal pressure and altered vagal innervation.,,, Both regurgitation and dysphagia have also been reported following LSG and may occur for similar reasons, with dysphagia potentially influenced by a narrow gastroesophageal junction, and delayed oesophageal empyting. Despite their association, the pathophysiological mechanisms linking gastric remanant shape and GORD are not well understood.
In this series, we aim to examine whether LSG gastric remnant shape is associated with early weight loss. We also explored the LSG shape with relation to the symptoms of reflux, regurgitation, or dysphagia at 12 months.
| Methods|| |
A retrospective cohort study was performed examining the relationship between post-LSG UGI swallow studies with short-term patient outcomes.,,,
Patients who underwent a LSG between June 2015 and June 2019 were considered for analysis. Patients who did not attend their follow-up appointment at 12 months or had inadequate imaging were excluded from the analysis. LSG was performed by two trained bariatric surgeons in three tertiary referral hospitals in Melbourne, Australia. Data were collected and managed prospectively using the REDCap (Research Electronic Data Capture) electronic data capture tool hosted at University of Melbourne., All patients completed a routine postoperative UGI contrast study between days 1 and 5. A complete contrast study was defined as adequate to visualize the entire stomach in multiple frames in an anterior-posterior series. The project was approved by the hospital Human Research Ethics Committee (LRR108/16).
Demographic information, GORD symptoms, and body mass index (BMI) were recorded preoperatively and again at the routine 12-month follow-up appointment. Reflux, regurgitation, and dysphagia were defined and graded as per the modified DeMeester score [Table 1]., Pre-existing symptoms were defined as any grade of symptom prior to LSG. Worsened symptoms were defined as progressing from lower to higher grade after LSG. Improved symptoms were defined as a change from a higher grade to lower grade or no symptoms. New symptoms were defined as progression from no symptoms to any grade symptom after LSG.
|Table 1: Modified DeMeester score used for reflux, regurgitation, and dysphagia|
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Access to the abdomen was achieved using a 12 mm optical trocar in left upper quadrant. After the establishment of pneumoperitoneum, additional 15 mm and two 5 mm ports were placed and the liver retracted using a Nathanson liver retractor (Cook Australia Ltd, Brisbane, Australia) introduced through an epigastric incision.
The stomach was mobilized along the greater curvature from 2 cm proximal to the pylorus to the angle of His using a vessel sealer. A 36 French Bougie was then placed into the stomach and a surgical stapler (Covidien Pty Ltd, Sydney, Australia) was used to form the gastric sleeve using an antral resection technique, resecting along the greater curvature from 2 cm proximal to the pylorus to 1 cm lateral to the angle of His. The top staple line was buried with 3-0 PDS suture and an omentopexy was performed with three interrupted 3-0 PDS sutures.
Evaluation of laparoscopic sleeve gastrectomy anatomy
UGI gastrograffin contrast studies were performed postoperatively between days 1 to 5 using gastrograffin contrast with the patient in the upright position. Fluroscopic images were taken using anterior-posterior and lateral view projections in a special magnified resolution. Gastric remnant shapes were classified using previously published sleeve shapes, namely tubular, proximal pouch, distal pouch or dumbbell shape.,,, Tubular shape was defined as the width of the entire gastric remnant being over >125% of the oesophageal width at its widest section in the anterior-posterior plane. A pouch was defined as the stomach width being over 125% the width of the esophagus either proximally or distally to the incisura. A dumbell shape was defined as having both proximal and distal pouches. A board-certified radiologist reviewed all the UGI contrast studies and anatomical classifications. These gastric remnant shapes are demonstrated diagrammatically in [Figure 1].
|Figure 1: Examples of laparoscopic sleeve gastrectomy shape types (a) tubular shape (b) proximal pouch, (c) distal pouch|
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Demographic data were analyzed with ANOVA Kruskal − Wallis test to assess for baseline differences between the anatomical groups. ANOVA Kruskal − Wallis test was used to assess for a difference between LSG anatomical shapes and weight loss followed by a subset analysis using the Mann-Whitney U-test. Sample size power calculations were performed and GORD symptom data was found to be underpowered. GORD symptom data was therefore presented using the descriptive statistics. P < 0.05 was considered to indicate statistical significance. Statistical analyses were performed using Graphpad Prism version 7.0 (GraphPad Software, California, USA).
| Results|| |
Four hundred and thirty-six patients underwent LSG within the study period. 377/436 patients attended regular long-term follow-up appointments (>6 months post-LSG and onward); however, only 280/436 patients attended the specific 12-month follow-up appointment and were therefore eligible to be included in the comparative analysis. 73/280 patients were excluded due to inadequate gastrograffin contrast studies being performed. 207 patients were included in the final analysis [Figure 2]. There were no significant differences in patient demographics, comorbidities or median preoperative BMI between the three different gastric remnant shapes except for higher rates of dyslipidemia in the distal pouch group [Table 2].
|Figure 2: Flow diagram of patient selection from prospective unit database|
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|Table 2: Patient demographics, comorbidities, and baseline body mass index for each laparoscopic sleeve gastrectomy gastric remnant shape|
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As per the study protocol, 159 (78%) patients were classified as having a tubular shape, 15 (7%) proximal pouch and 33 (16%) distal pouch. No patient was classified as having a dumbbell shape.
Patients classified as having a tubular gastric remnant shape had significantly greater median BMI loss at 12 months postoperatively compared to the proximal pouch (11.3 kg/m2 vs. 10.2 kg/m2, P = 0.01) [Figure 3]. The median BMI loss at 12 months was greater in tubular shape compared to distal pouch however this did not reach statistical significance [11.3 kg/m2 vs. 10.6 kg/m2, P = 0.3, [Table 3]]. There was no significant difference in median BMI loss in patients classified as having distal or proximal pouch (10.6 kg/m2 vs. 10.2 kg/m2, P = 0.24).
|Figure 3: Difference in body mass index (kg/m2) loss at 12 months according to LSG anatomical shape. * (11.3 kg/m2 vs. 10.2 kg/m2, P = 0.01)|
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|Table 3: Loss of body mass index at 12 months postlaparoscopic sleeve gastrectomy for different sleeve configurations|
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Reflux was preexisting in 55% of our patients. Two percent of patients developed new reflux postoperatively and 4% had worsened reflux symptoms. The majority of patients had low grade symptoms preoperatively [Figure 4]. Regurgitation and dysphagia had much lower rates of preexisting disease. There was no relationship in reflux, regurgitation, or dysphagia symptoms between the shape types [Table 4].
|Figure 4: Patients (n = 207), preoperative modified DeMeester score (Grade 0, 1, 2 or 3) for reflux, regurgitation and dysphagia|
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|Table 4: Incidence of preoperative, improved, worsened or new reflux, regurgitation and dysphagia at 12 months' follow-up|
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| Discussion|| |
LSG is an effective weight loss procedure,, where partial gastrectomy results in anatomical and hormonal changes to produce weight loss.,, Optimization of sleeve technique is often discussed as important; however, the impact of sleeve shape on weight loss and symptomatology has not been thoroughly assessed., Whilst every attempt at surgery is made to achieve uniform sleeve anatomy, there are uncontrollable factors which influence postoperative configuration such as patient and surgeon variation, gastric peristalsis, and postoperative gastric contraction.
In this series, the majority of LSG patients achieved the desired tubular sleeve configuration. We found that LSG patients with a tubular shaped gastric remnant had a significantly greater median BMI loss at 12 months compared to LSG patients with a proximal pouch. This finding is novel in the literature as only a few studies have examined LSG gastric remnant shape and its relationship with weight loss.,,
A similar retrospective cohort study in 100 LSG patients examined weight loss at 6 months with sleeve shape categorized into upper pouch, lower pouch, dumbbell and tubular shapes with gastrograffin contrast studies. They found a trend toward greater weight loss with tubular shape; however, it was not statistically significant. It is possible that these results may have reached significance with follow-up at 12 months or with a greater sample size such as in our study.
A larger retrospective study by Saleh et al. in 210 patients examined gastric shape and weight loss using UGI contrast studies performed day one post-LSG. It used a similar gastric remanant classification with patients defined as having either a dumbbell, upper pouch, lower pouch or tubular configuration but found no significant correlation with weight loss. In this study, an antral preserving surgical technique was performed with gastric resection commencing 5 cm from the pylorus. In our own series, an antral resection technique was used with resection commencing 2 cm proximal to the pylorus (see “surgical technique” in the methods section). The use of our described antral resection technique would logically lead to a more tubular shape while antral preservation technique would create more distal pouches. This idea is supported by Saleh et al.(using antral preservation) finding distal pouches present in 39.2% of LSG patients while we had distal pouches in 16% of patients. A recent systematic review including six randomized controlled trials found that antral resection was associated with 9% more weight loss at 24 months compared to antral preservation.,, A distal pouch may therefore be associated with antral preservation technique and therefore be correlated with weight loss which could explain the difference in findings between the studies.
Gastric remnant shape could also be surrogate marker for overall gastric volume, with proximal and distal pouches presumably having a greater gastric remnant volume than tubular shape. The relationship between LSG gastric volume and weight loss is contentious;,,,,,,,,,, however, several radiological studies have found that gastric remnant volume is inversely related to weight loss at 12 months., A small retrospective study of 45 LSG patients examined gastric remnant volume using UGI contrast studies and found that larger gastric remnant volume at 12 months was inversely correlated with weight loss at 18 months. Similarly, Pañella et al. examining 50 LSG patients with UGI contrast studies showed that gastric remnant volume was inversely correlated with weight loss at 12 months, however, this relationship did not continue in the long term at 5 years' follow-up.
Our study found no clear relationship between gastric remnant shape and post-LSG symptoms of GORD, regurgitation and dysphagia. This finding is consistent with the limited data published in the literature. It is likely that mechanisms relating to reflux, regurgitation, and dysphagia following sleeve gastrectomy are complex and a simple analysis of gastric remnant shape is insufficient to detect them. The power to detect subtle findings in this cohort is also reduced by the different sample sizes in the three shape groups. It is also possible that the presence of a hiatus hernia could also impact postoperative GORD symptoms which was not explored in our study.
We found that 55% of all patients had preexisting reflux which is similar to a large national registry study which found that 45% patients had reflux before LSG. In regards to reflux and gastric remnany shape, Saleh et al. also observed no correlation between post-LSG sleeve shape with UGI contrast studies and de novo reflux in 210 patients. By contrast, Lazoura et al. examined 85 LSG patients and found an increase in regurgitation at 12 months in patients with tubular shape stomach. It is difficult to explain that contradictory results in these studies, however, the magnitude of dilation is not quantified in these studies and could be an important factor in determining the relationship between symptomatology and shape. A large pouch would allow increased volume to enter the stomach which could lead to increased intraluminal gastric pressure resulting in new or worsening reflux or regurgitation. In addition, narrowing at the incisura is regarded as a possible determinant of reflux and is not assessed in the studies, including our own. On the basis of this data and other published literature, it is difficult to assess if there is any correlation between the configuration of the gastric remnant and reflux, regurgitation and dysphagia.
This study has several limitations. Radiological studies were performed at three different hospitals and, as such, subtle local UGI swallow study protocol variations could not be accounted for. We have attempted to overcome this limitation by excluding patients with poor quality swallow studies (defined as not having either lateral or anterior-posterior views) and using objective imaging analysis criteria combined with a board-certified radiologist review to provide more accurate and consistent anatomical classification. Poor patient follow-up may also bias results. While 86% of patients attended follow-up, only 64% of patients attended the specific 12 month appointment and were therefore included in this series thus reducing the sample size and power of the study. In addition, the clinical significance of a 1.1 kg/m2 difference in BMI between anatomical groups is questionable; however, it remains an interesting finding. While this study examined early weight loss at 12 months, it remains unclear whether the correlation between gastric remnant shape and weight loss will continue with long term weight loss (18 months and onwards). The impact of postoperative compliance to lifestyle modification has also not been explored in our study and this may have influenced the findings. There are also a low number of proximal shape types in our cohort (presumably because our surgeons aim for tubular shape intra-operatively), and therefore, conclusions should be drawn with caution. We found that the distal pouch had statistically higher rates of preoperative dyslipidemia compared to the other shape types. We cannot biologically explain this finding and it may be spurious; however, further research is required to investigate its significance. In spite of these difficulties, this is one of the largest published studies which assess short-term implications of gastric sleeve anatomy. A statistically significant relationship between sleeve shape and weight loss is identified supporting the need for precise anatomical surgical resection.
| Conclusion|| |
LSG patients with tubular gastric remnant shape have greater 12-month weight loss compared to those with proximal pouch. Gastric remnant configuration was not related to postoperative reflux, regurgitation or dysphagia. Future studies should examine the impact of post-LSG anatomical shape on long-term weight loss to ascertain whether this relationship continues over time as well as explore the whether antral resection surgical technique leads the optimal configuration.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]