Review ArticleImpact of Laparoscopic Sleeve Gastrectomy onGastrointestinal Motility

Eleni Sioka, George Tzovaras, Konstantinos Perivoliotis , Vissarion Bakalis, Eleni Zachari,Dimitrios Magouliotis, Vassiliki Tassiopoulou, Spyridon Potamianos, Andreas Kapsoritakis,Antigoni Poultsidi, Konstantinos Tepetes , Constantine Chatzitheofilou,and Dimitris Zacharoulis

Department of Surgery, University Hospital of Larissa, Larissa, Greece

Correspondence should be addressed to Dimitris Zacharoulis; zachadim@yahoo.com

Received 24 December 2017; Accepted 4 March 2018; Published 5 April 2018

Academic Editor: Riccardo Casadei

Copyright © 2018 Eleni Sioka et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. Laparoscopic sleeve gastrectomy (LSG) was considered mainly as a restrictive procedure due to anatomic alterations inthe upper gastrointestinal tract. Additionally, due to neurohormonal alterations, LSG modifies the gastrointestinal motility, whichcontrols appetite and feeling of satiety. Aim. The aim of the study was to review the impact of laparoscopic sleeve gastrectomy ongastrointestinal motility.Material and Methods. A search of the medical literature was undertaken in Pubmed, Web of Science, andCochrane library. Esophageal, gastric, bowel motility were assessed separately. Results. Nine studies assessed esophageal motility.The data remain debatable attributing to the heterogeneity of follow-up timing, surgical technique, bougie size, and distancefrom pylorus. The stomach motility was assessed in eighteen studies. Functionally, the sleeve was divided into a passive sleeveand an accelerated antrum. All scintigraphic studies revealed accelerated gastric emptying after LSG except of one. Patientsdemonstrated a rapid gastroduodenal transit time. The resection of the gastric pacemaker had as a consequence aberrant distalectopic pacemaking or bioelectrical quiescence after LSG. The bowel motility was the least studied. Small bowel transit time wasreduced; opposite to that the initiation of cecal filling and the ileocecal valve transit was delayed. Conclusion. Laparoscopic sleevegastrectomy has impacts on gastrointestinal motility. The data remain debatable for esophageal motility. Stomach and smallbowel motility were accelerated, while the initiation of cecal filling and the ileocecal valve transit was delayed. Furtherpathophysiological studies are needed to evaluate the correlation of motility data with clinical symptoms.

1. Introduction

Laparoscopic sleeve gastrectomy (LSG) is the most fre-quently performed procedure in the world and has overtakenthe “gold standard” Roux-en-Y gastric bypass (RYGB),which remains the most performed bariatric/metabolicprocedure only in Latin/South America. The trend analysisdemonstrated that LSG had the largest average annualpercentage increase of approximately 9% from 2013 of theworldwide bariatric/metabolic surgical procedures [1]. Lapa-roscopic sleeve gastrectomy is positioned between the adjust-able gastric banding and RYGB in terms of morbidity witheffectiveness comparable to RYGB even at five years [2, 3].

Laparoscopic sleeve gastrectomy involves the removal ofthe gastric fundus and greater curvature portion of thestomach, leaving only a lesser curvature tube. Yehoshuaet al. showed that after the sleeve, the fundus, which is themost distensible part of the stomach, is removed, thus leavinga sleeve which is characterized by markedly lesser distensibil-ity and high intraluminal pressure, leading to the feeling ofearly satiety [4]. The abstraction of the fundus is related tophysiological alterations in the upper gastrointestinal tract,since the angle of His and the receptive relaxation mecha-nism is abolished, and the gastric pacemaker is abandoned.Furthermore, the antrum is preserved in some cases depend-ing on the distance of the resection, and the pylorus remains

HindawiGastroenterology Research and PracticeVolume 2018, Article ID 4135813, 17 pageshttps://doi.org/10.1155/2018/4135813

intact. These physiological changes are expected to provokemotility alterations at the gastrointestinal tract.

The aim of the study was to review the impact of laparo-scopic sleeve gastrectomy on gastrointestinal motility.

2. Material and Methods

2.1. Search Strategy. A search of the medical literature wasundertaken in Pubmed, Web of Science, and Cochranelibrary until August 2017. The keywords used were “sleevegastrectomy” AND (motility OR gastrointestinal motilityOR esophageal motility OR gastric motility OR bowel motil-ity OR emptying OR manometry).

2.2. Eligibility Criteria

2.2.1. Types of Studies. All studies assessing the impact ofLSG on gastrointestinal motility were included. Esophageal,stomach, and bowel motilities were assessed separately.

2.2.2. Types of Participants. The types of participantswere obese patients (BMI > 30) undergoing laparoscopicsleeve gastrectomy.

2.2.3. Types of Outcome Measures. The outcomes measuredwere esophageal, gastric, and bowel motility.

2.3. Inclusion and Exclusion Criteria. Two independentreviewers (Eleni Sioka and Konstantinos Perivoliotis) screenedabstracts, reviewed full text versions of all studies classified,and extracted data. Any trial considered relevant wasretrieved for further review. The full texts were indepen-dently assessed by two reviewers. Disagreements wereresolved with a third reviewer. Only published articles inthe English language were included. Meta-analysis, system-atic reviews, letters to the editor, case studies, non-Englishlanguage publications, duplicate studies, experimentalstudies, and conference papers were excluded.

2.4. Data Extraction and Quality Assessment. One reviewer(Konstantinos Perivoliotis) extracted data from selected trialsand a second reviewer (Eleni Sioka) checked for accuracy.The data were standardized and extracted from each study,and data were recorded into a database. The variables col-lected were first author, year of publication, country, type ofstudy, number of participants, method of assessment, timingpoints, and main findings.

3. Results

3.1. Study Selection. One hundred seventy eight studies werescreened for eligibility and fifty two studies assessed in fulltext. Twenty four studies were excluded due to various rea-sons. Finally, 28 studies were eligible to be included in thereview (Figure 1). There was complete agreement amongthe authors as to the inclusion of these studies.

3.2. Esophageal Motility. Nine studies assessed esophagealmotility. Two studies were conducted in Greece [5, 6], onein France [7], two in Italy [8, 9], one in Argentina [10], one

in Netherlands [11], one in Germany [12], aand one in Chile[13]. All except of one [7] were prospective studies.

The postoperative follow-up ranged from 6 days to 50months. The bougie size ranged from 32 to 40F. The distancefrom the pylorus ranged from 2 to 6 cm. The lower esoph-ageal sphincter (LES) length was reduced in three studies[5, 9, 13] increased in two studies [6, 10], and unchangedin one study [8]. The LES resting pressure decreased infour studies [5, 10, 11, 13], increased in two studies [6, 12],and remained unchanged in two studies [8, 9]. The ampli-tude pressure was reduced in two studies [5, 11], increasedin one study [10], and unchanged in one study [8]. Ampli-tude pressure decreased in distal esophagus and increasedin the other parts in one study [6]. Ineffective motility wasreported in four studies. The percentage was increased from10% to 45% postoperatively in one study [9], while it wasthe same preoperatively (7%) in another study [10], wasincreased at 5% (1/20 patients) in one study [11], and wasreported at 37.7% (20/53 patients) in another study [7]. The

91 recordsidentified

through MEDLINE

15 recordsidentifiedthrough

CENTRAL

74 duplicates removed

178 recordsscreened

52 full-textarticles assessed

for eligibility

24 full-text articlesexcluded

28 studiesincluded in

qualitative andquantitative

synthesis

126 recordsexcluded

9 nonhumanstudies

3 non-Englisharticles

59reviews/conference

abstracts55 irrelevant

records

9 articlesconcerning

esophageal motility18 articles

concerning gastricmotility3 articles

concerning bowelmotility

24 irrelevant studies

146 recordsidentified

through Web ofScience

Figure 1: Flow diagram.

2 Gastroenterology Research and Practice

percentage of normal peristaltic contractions was not affectedin one study [11], while it increased in another study [5]. Thesummary of studies is reported in Table 1.

3.3. Stomach Motility. Eighteen studies assessed stomachmotility. Eleven studies were conducted in Europe (Spain[n = 2] [14, 15], Italy [n = 3] [16–18], Greece [n = 3][19–21], Czech Republic [n = 1] [22], Germany [n = 1] [23],and the Netherlands [n = 1] [24]), whereas one study wasperformed in the USA [25], two studies in India [26, 27],one study in New Zealand [28], one in Egypt [29], one inChile [30], and one in Israel [31]. Twelve studies were pro-spective studies, four studies were prospective randomizedcontrolled studies [14, 17, 22, 27], and two were retrospectivestudies [18, 25]. The method of gastric emptying assessmentwas gastric scintigraphic studies in fourteen studies andmagnetic resonance imaging (MRI) in one study [23], whileone study assessed the gastric slow-wave pacemaking usinglaparoscopic high-resolution (HR) electrical mapping [28],and two studies assessed the gastroduodenal transit time byradiological upper gastrointestinal series [18, 25].

The postoperative follow-up ranged from 3 to 24months.The bougie size ranged from 32 to 48F. The distance fromthe pylorus ranged from 2 to 8 cm. All studies showedaccelerated gastric emptying after LSG except for one[31]. Functionally, the sleeve was divided into a passivesleeve and an accelerated antrum. The patients demon-strated a rapid gastroduodenal transit time. The resectionof the gastric pacemaker had as a consequence aberrant dis-tal ectopic pacemaking or bioelectrical quiescence after LSG.No correlation was observed between gastric emptying andpostprandial symptoms in one study. No correlation wasfound between gastroduodenal transit time and weight lossin one study [25], while in another study, patients showinga rapid gastroduodenal transit had better weight loss thanpatients presenting with a slow voiding rate [18]. Thesummary of the studies are presented in Table 2.

3.4. Bowel Motility. Three studies assessed the bowel motility.Two were prospective studies and one was prospectiverandomized study. One study was conducted in Japan, onein Greece, and one in India [21, 27, 32]. Trung et al. evaluatedthe intestinal motility using cine MRI preoperatively and 3months postoperatively and found reduced intestinal transittime leading to accelerated intestinal motility [32]. Melissaset al. evaluated prospectively 21 patients preoperatively witha g-camera and 4 months postoperatively. Apart from theacceleration of small bowel transit time, the authors showedthat initiation of cecal filling and the ileocecal valve transitwas delayed [21]. Similarly, Shah et al. showed decreasedsmall bowel transit time after LSG [27] (Table 3).

4. Discussion

The aim of this study was to review the impact of laparo-scopic sleeve gastrectomy on gastrointestinal motility. Thegastrointestinal motility research might be essential to recog-nize the behavior of the created sleeve, to explain possibleclinical symptoms-implications, and to elucidate possible

mechanisms of actions of this procedure. According to theSecond International Consensus Summit for Sleeve Gastrec-tomy, the panel of experts voted the following as mechanismsof action: restriction: 79%, gastric emptying: 0%, hormonal:16%, malabsorption: 0%, and other: 3% [33]. Since 2007,LSG was characterized as more than a restrictive procedure[19]. Additional supportive evidence came from studiesassessing hormonal alterations after LSG. Concerning hor-monal changes, it seems that patients experienced a pro-nounced and long-lasting decrease of circulating ghrelinand increased postprandial release of the CCK, GLP-1, andPYY, the so-called gut peptides after LSG. It was hypothe-sized that the faster delivery of nutrients to the distalintestinal tract postoperatively may provoke increased thepostprandial release of the gut peptides contributing to theimprovement of glucose control as well as to the reductionof food intake and subsequently body weight [34].

The esophageal motility was assessed in several studies.The limitations of the studies include the small sample size.The data remain debatable. The variability in the outcomesof esophageal motility may be attributable to the timing ofpostoperative follow-up, the variability of surgical tech-niques, the different bougie sizes, and the different dissec-tions from pylorus, thus creating a sleeve with variabledistensibility and intraluminal pressure with, in part, thepreservation of the antrum. The percentage of peristalticnormal contractions increased postoperatively and is notstatistically significant at 3 months [11] but statisticallysignificant later [5]. It seems that the motility of the body ofthe esophagus was normalized. Perhaps, this might beattributable to the reduced intrabdominal pressure due toweight loss. An increase in the esophageal acidification wasreported in few studies [9, 11]. Del Genio et al. pointedout a decrease in the esophageal transit after LSG inimpedance study. Furthermore, the authors explained thereflux episodes as a consequence of retrograde movementsinto the esophagus [9].

Gastric motility emerges as the role of the stomach as anendocrine organ. Gastric motility acts as a central mediatorof hunger, satiation, and satiety. Gastric emptying plays akey role in regulating food intake. Gastric distention acts asatiety signal to inhibit food intake [35]. During food intake,it is the gastric distention and gastric accommodation thatregulate satiation in a manner. After food intake, when thestomach empties gradually, it is the gastric emptying andthe intestinal exposure of the nutrients that play a key role,while the role of gastric distention follows. It seems thatgastric accommodation and gastric emptying are implicatedin the regulation of gastric distention and intestinal exposureof nutrients, thus control satiation and satiety. The correla-tions between gastric accommodation, gastric emptying,and body weight suggest that gastric motility may also affectthe long-term regulation of body weight [36].

A number of studies assessed gastric motility. Baumannet al. showed that the sleeve was completely motionlesswithout any coordinate peristalsis, while the antrum hadfaster peristaltic folds, concluding that gastric emptying isdirectly linked to the function of the antrum when theantrum is preserved in LSG [23]. It seems that the resection

3Gastroenterology Research and Practice

Table1:Stud

iesassessingesop

hagealmotility.

No.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients

Metho

dof

assessment/

follow-up

Distancefrom

pylorus/bougiesize

Mainfind

ings

ofthestud

y

1Sioka,E.etal.,

2017

[5],Greece

Prospective

stud

y18

Esoph

agealm

anom

etry

preoperativelyandat

medianintervalof

7mon

ths

5cm

/36F

The

lower

esop

hagealsphincter(LES)

totallengthdecreased

postop

eratively(p

=0002).T

herestingandresidu

alpressurestend

edto

decrease

postop

eratively(m

ean

difference

[95%

confi

denceinterval]:−4

[−8.3/0.2]

mmHg,

p=0 0

60;−

1.4[−3/0.1]

mmHg,p=0071,resp.).T

heam

plitud

epressure

decreasedfrom

95.7±37.3to

69.8±26.3mmHgattheup

perborderofLE

S(p

=0 0

14)and

tend

edto

decrease

atthedistalesop

hagusfrom

128.5±30.1

to112.1±3

5.4mmHg(p

=006)andmidesop

hagusfrom

72.7±34.5to

49.4±16.7mmHg(p

=0 0

06).The

peristaltic

norm

alsw

allowpercentage

increasedfrom

47.2±36.8to

82.8±28%

(p=0 0

03).The

postop

erativeregurgitationwas

stronglynegativelycorrelated

withLE

Stotallength

(Spearman’sr=−0

670).W

hengrou

pswerecompared

accordingto

heartburnstatus,the

statisticalsignificancewas

observed

betweenthegrou

psof

improvem

entand

deteriorationregardingpo

stop

erativeresidu

alpressure

and

postop

erativerelaxation

(p<0002a

ndp<0002,resp.).

Withregard

toregurgitationstatus,there

was

statistically

significant

difference

betweengrou

psregardingpreoperative

amplitud

epressure

attheup

perborder

ofLE

S(p

<0056).

PatientsdevelopeddecreasedLE

Slength

andweakenedLE

Spressure

afterLSG.E

soph

agealb

odyperistalsiswas

also

affectedin

term

sof

decreasedam

plitud

epressure,especially

attheup

perborderofLE

S.Nevertheless,body

peristalsiswas

norm

alized

postop

eratively.LSGmight

notdeteriorate

heartburn.

Regurgitation

might

increase

followingLSGdu

eto

shortening

ofLE

Slength,p

articularlyin

patientswith

rangeofpreoperative

amplitud

epressureattheup

perborder

ofLE

Sof

38.9–92.6mmHg.

2Mion,

F.etal.,

2016

[7],France

Retrospective

stud

y53

High-resolution

impedancemanom

etry

Sleeve

volumeand

diam

eter

withCTscan

Medianfollow-upat

11mon

ths(1–50)

NR/N

R

The

increasedintragastricpressure

occurred

very

frequently

inpatientsafterSG

(77%

)andwas

notassociated

withany

upperGIsymptom

s,specificesop

hagealmanom

etricprofi

le,

orim

pedancereflux.Impedancereflux

episod

eswerealso

frequentlyobserved

afterSG

(52%

):they

weresignificantly

associated

withgastroesop

hagealreflux

(GER)symptom

sandineffective

esop

hagealmotility.T

hesleeve

volumeand

diam

eterswerealso

significantlysm

allerin

patientswith

impedancereflux

episod

es(p

<001).

4 Gastroenterology Research and Practice

Table1:Con

tinu

ed.

No.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients

Metho

dof

assessment/

follow-up

Distancefrom

pylorus/bougiesize

Mainfind

ings

ofthestud

y

SGsignificantlymod

ified

esop

hagogastricmotility.T

heIIGP

isfrequent,n

otcorrelated

tosymptom

sandshou

ldbe

regarded

asaHRIM

markerof

SG.T

heim

pedancereflux

episod

eswerealso

frequent,associatedwithGERsymptom

sandesop

hagealdysm

otility.H

RIM

may

thus

have

aclinical

impacton

themanagem

entof

patientswithup

perGI

symptom

safterSG

.

3Rebecchi,F.

etal.,

2014

[8],Italy

Prospective

clinicalstud

y65

Clin

icallyvalid

ated

question

naire,up

per

endo

scop

y,esop

hageal

manom

etry,and

24-hou

rpH

mon

itoringbefore

and

24mon

thsafterLSG.

6cm

/36F

Onthebasisof

preoperative

24-hou

rpH

mon

itoring,

patientsweredividedinto

grou

pA(patho

logic,n=28)and

grou

pB(normal,n

=37).The

symptom

sim

proved

ingrou

pA,w

iththegastroesop

hagealreflux

diseasesymptom

assessmentscalescoredecreasing

from

53.1±10.5to

13.1±3.5(p

<0001).T

heDeM

eester

scoreandtotalacid

expo

sure

(%pH

<4)

decreasedin

grou

pApatients

(DeM

eester

scorefrom

39.5±16.5to

10.6±5.8,p<0 0

01;

%pH

<4from

10.2±3.7to

4.2±2.6,p<00

01).Reald

eno

voGERDoccurred

in5.4%

ofgrou

pBpatients.N

osignificant

changesin

thelower

esop

hagealsphincter

pressure

andesop

hagealperistalsisam

plitud

ewerefoun

din

both

grou

ps.

LSGim

proves

symptom

sandcontrolsreflux

inmost

morbidlyobesepatientswithpreoperative

GERD.Inobese

patientswitho

utpreoperative

evidence

ofGERD,the

occurrence

ofde

novo

reflux

isun

common

.Therefore,L

SGshou

ldbe

considered

asan

effective

option

forthesurgical

treatm

entof

obesepatientswithGERD.

4Gorod

ner,V.

etal.,2015

[10],

Argentina

Prospective

stud

y14

Esoph

agealm

anom

etry

(EM)and24

hpH

mon

itoringbefore

and

1year

afterLSG.

6cm

/36F

The

lower

esop

hagealsphincter(LES)

length

increasedfrom

2.7to

3.2cm

(p=NS

),andLE

Spressure

decreasedfrom

17.1to

12.4mmHg(p

≤005).Preop

eratively,LE

Swas

norm

otensive

in13

(93%

)patients;postoperatively,LESwas

norm

alin

10(71%

)(p

=NS

).After

LSG,the

LESP

significantlydecreased

5Burgerhart,J.S.

etal.,2014

[11],

Netherlands

Prospective

stud

y20

Esoph

agealfun

ctiontests

(high-resolution

manom

etry

(HRM),24-h

pH/impedancemetry)

before

and3mon

ths

afterLSG

6cm

/34F

Esoph

agealacidexpo

sure

significantlyincreasedafter

sleeve

gastrectom

y:up

rightfrom

5.1±4.4to

12.6±9.8%

(p=0 0

03),supine

from

1.4±2.4to11

±15%(p

=00

03)and

totalacidexpo

sure

from

4.1±3.5to

12±10.4%

(p=0 0

04).

The

percentage

ofno

rmalperistalticcontractions

remained

unchanged,bu

tthedistalcontractile

integraldecreasedafter

LSGfrom

2006.0±1806.3to

1537.4±1671.8mmHg·cm·s

(p=001).The

lower

esop

hagealsphincter(LES)

pressure

decreasedfrom

18.3±9.2to

11.0±7.0mmHg(p

=0 0

2).

5Gastroenterology Research and Practice

Table1:Con

tinu

ed.

No.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients

Metho

dof

assessment/

follow-up

Distancefrom

pylorus/bougiesize

Mainfind

ings

ofthestud

y

After

LSG,the

patientshave

significantlyhigher

esop

hageal

acidexpo

sure,w

hich

may

wellbedu

etoadecreaseintheLE

Srestingpressure

followingtheprocedure.

6DelGenio,J.etal.,

2014

[9],Italy

Prospective

stud

y25

High-resolution

impedancemanom

etry

(HRiM

)andcombined

24hpH

andmultichannel

intralum

inalim

pedance

(MII-pH).

Medianfollow-upat

13mon

ths

NR/40F

Unchanged

LESfunction

,increased

ineffective

peristalsis,

andincompletebolustransit.MII-pH

show

edan

increase

ofboth

acid

expo

sure

oftheesop

hagusandnu

mberof

nonacid

reflux

eventsin

postprandialperiod

s.Laparoscop

icSG

isan

effective

restrictiveprocedurethat

createsdelayedesop

hagealem

ptying

witho

utim

pairingLE

Sfunction

.Acorrectlyfashionedsleeve

does

notindu

cede

novo

GERD.R

etrogrademovem

entsandincreasedacid

expo

sure

areprobablydu

eto

stasisandpo

stprandial

regurgitation.

7Kleidi,E.etal.,

2013

[6],Greece

Prospective

stud

y23

Esoph

agealm

anom

etry

preoperativelyand6weeks

postop

eratively

3-4cm

/34F

The

LEStotaland

abdo

minallengthsincreasedsignificantly

postop

eratively,whereas

thecontractionam

plitud

ein

the

lower

esop

hagusdecreased.

There

was

anincrease

inreflux

symptom

spo

stop

eratively(p

<0009).T

heapproxim

ationof

theangleof

Hismostlyfrom

theop

eratingsurgeonresulted

inan

increasedabdo

minalLE

Slength

(p<001).The

presence

ofesop

hagealtissue

inthespecim

encorrelated

with

theincreasedtotalG

ERD

score(p

<005).

LSGweakens

thecontractionam

plitud

eof

thelower

esop

hagus,which

may

contribu

teto

postop

erativereflux

deterioration.

Italso

increasesthetotaland

theabdo

minal

lengthsof

theLE

S,especiallywhentheangleof

Hisismostly

approxim

ated.H

owever,ifthisapproxim

ationleadsto

esop

hagealtissue

excision

,the

reflux

isagainaggravated.

Thu

s,staplin

gtoocloseto

theangleof

Hisshou

ldbe

done

cautiously.

8Petersen,

W.V

.etal.,2012

[12],

Germany

Prospective

stud

y

37Group

I(BMI=

19–2

5)20

(con

trol

grou

p)Group

II(BMI=

42–6

5)20

patients

(8mon

ths)

Group

III

(BMI=

37–5

7)17

patients

(6days)

Esoph

agealm

anom

etry

2cm

/35Ch

Postoperatively,the

LESP

increasedsignificantly,n

amely,

from

preoperative

8.4to

21.2mmHgin

grou

pIIandfrom

11to

24mmHg(p

<00001)in

grou

pIII.The

tubu

lar

esop

hagealmotility

profi

tsfrom

LSG.

The

LSGsignificantlyincreasedthelower

esop

hageal

pressure

independ

entof

weightloss

afterLSGandmay

protectobesepatientsfrom

gastroesop

hagealreflux.

6 Gastroenterology Research and Practice

Table1:Con

tinu

ed.

No.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients

Metho

dof

assessment/

follow-up

Distancefrom

pylorus/bougiesize

Mainfind

ings

ofthestud

y

9Braghetto,I.etal.,

2010

[13],C

hile

Prospective

stud

y20

Esoph

agealm

anom

etry

preoperatively,6

mon

ths

postop

eratively

2cm

/32F

Preop

erativemeanLE

SPwas

14.2±5.8mmHg.The

postop

erativemanom

etry

decreasedin

17/20(85%

),witha

meanvalueof

11.2±5.7mmHg(p

=00

1).Seven

ofthem

presentedLE

SPof

<12mmHgandtenpatientspresented

LESP

of<6

mmHgaftertheop

eration.

Furtherm

ore,the

abdo

minallength

andtotallengthof

thehigh

pressure

zone

attheesop

hagogastricjunction

wereaffected.

Asleeve

gastrectom

yprod

uces

anim

portantd

ecreasein

LES

pressure,w

hich

can,

inturn,cause

theappearance

ofreflux

symptom

sandesop

hagitisaftertheop

erationdu

eto

apartial

resectionof

theslingfibersdu

ring

thegastrectom

y.

7Gastroenterology Research and Practice

Table2:Stud

iesassessingstom

achmotility.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients(N

)Metho

dof

assessment/

follow-uppo

ints

Bou

giesize/distance

from

pylorus

Mainfind

ings

ofthestud

y

1Vives,M

.etal.,

2017

[14],Spain

Prospective

rand

omized

stud

y

60(30patientswiththe

sectionat3cm

and30

patients

withthat

at8cm

from

thepylorus

Gastricem

ptying

byscintigraphy

(T1/2min),gastricvolumeby

CT

scan

(cc)

at6and12

mon

ths

38F/3cm

/8cm

Gastricem

ptying

increasesthespeedsignificantly

inboth

grou

psbu

tisgreaterin

the3cm

grou

p(p

<0 0

5).

Whendividing

grou

psinto

type

2diabeticpatients

andno

ndiabeticpatients,the

speedin

nond

iabetic

patientsissignificantlyhigher

forthe3cm

grou

p.The

residu

alvolumeincreasessignificantlyin

both

grou

ps,and

thereareno

differencesbetweenthem

.Gastricem

ptying

isfaster

inpatientswithantrum

resection.

The

distance

does

notinfluencethegastric

emptying

ofdiabeticpatients.

2Berry,R

.etal.,

2017

[28],

New

Zealand

Prospective

stud

y8(1

patientwithchronic

refux,nausea,and

dysm

otility)

Laparoscop

ichigh-resolution

(HR)electricalmapping

before

andafterLSG

NR

The

baselin

eactivity

show

edexclusivelyno

rmal

prop

agation.

AcutelyafterLSG,allpatients

developedeither

adistalun

ifocalectop

icpacemaker

withretrograde

prop

agation(50%

)or

bioelectricalq

uiescence(50%

).The

prop

agation

velocitywas

abno

rmallyrapidafterLSG(12.5±0.8

versus

baselin

e3.8±0.8mms−

1 ;p=00

1),w

hereas

thefrequencyandam

plitud

ewereun

changed

(2.7±0

.3versus

2.8±0.3cpm,p

=0 7

;1.7±0.2

versus

1.6±0.6mV,p

=0 7

).In

thepatientwith

chronicdysm

otility

afterLSG,m

apping

also

revealed

astableantralectopicpacemaker

with

retrograde

rapidprop

agation(12.6±4.8mms−

1 ).

The

resectionof

thegastricpacemaker

during

LSG

acutelyresultedin

aberrant

distalectopic

pacemakingor

bioelectricalq

uiescence.

Ectop

icpacemakingcanpersistlong

afterLSG,

indu

cing

chronicdysm

otility.

The

clinicalandtherapeuticsignificanceof

these

find

ings

nowrequ

irefurtherinvestigation.

3Sista,F.

etal.,

2017

[16],Italy

Prospective

stud

y52

Gastricem

ptying

scintigraphy

for

liquidandsolid

food

s,before

and

3mon

thsafterLSG.

36F/5cm

After

surgery,T1/2was

significantlyaccelerated:

15.2±13

min

and33.5±18

min

intheLgrou

pand

Sgrou

p,respectively(p

<05).In

both

grou

ps,

GLP

-1plasmaconcentrations

wereincreasedat

each

bloodsamplingtime:2.91

±2.9pg/m

L,3.06

±3.1pg/m

L,and3.21

±2.6pg/m

Lat

15,30,

and60

minutes,respectively,(p

<05)fortheL

grou

pand2.72

±1.5pg/m

L,2.89

±2.1pg/m

L,2.93

±1.8pg/m

L,and2.95

±1.9pg/m

Lat

30,60,

8 Gastroenterology Research and Practice

Table2:Con

tinu

ed.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients(N

)Metho

dof

assessment/

follow-uppo

ints

Bou

giesize/distance

from

pylorus

Mainfind

ings

ofthestud

y

90,and

120minutes,respectively,(p

<05)forthe

Sgrou

p.After

LSG,G

LP-1

and%GRpresenteda

negative

linearcorrelation(r)at

each

blood

samplingtimein

both

grou

ps.R

apid

gastric

emptying

3mon

thsafterLSG

4Vigneshwaran,B

.etal.,2016

[26],

India

Prospective

stud

y20

withT2D

Mandwitha

BMIof

30.0–35.0kg/m

2

The

gastricem

ptying

times

were

measuredatbaselin

e,3mon

ths,6

mon

ths,12

mon

ths,and24

mon

thsaftersurgery.

36F/4cm

There

was

asignificant

decrease

ingastric

emptying

time.

Accelerated

gastricem

ptying

5Mans,E.etal.,

2015

[15],Spain

Prospective

comparative

stud

y

Three

grou

pswerestud

ied:

morbidlyobesepatients

(n=16),morbidlyobese

patientswho

hadhadsleeve

gastrectom

y(n

=8),and

nono

bese

patients(n

=16)

Gastricandgallbladd

erem

ptying

42F/5cm

The

antrum

area

during

fastingin

morbidlyobese

patientswas

statistically

significantlylarger

than

that

intheno

nobese

andsleeve

gastrectom

ygrou

ps.G

astricem

ptying

was

acceleratedin

the

sleeve

gastrectom

ygrou

pcomparedwiththeother

2grou

ps(w

hich

hadvery

similarresults).

Gallbladd

erem

ptying

was

similarin

the3grou

ps.

Gastricem

ptying

was

acceleratedin

thesleeve

gastrectom

ygrou

pcomparedwiththeother2

grou

ps(w

hich

hadvery

similarresults)

6Kandeel,A

.A.etal.,

2015

[29],E

gypt

Prospective

stud

y40

Tc-sulfu

rcolloid

GEscintigraphy

was

performed

onallp

atients

subm

ittedto

LSGbeforeandafter

surgery(1–4

weeks

forliq

uids

and4–6weeks

forsolid

s)

36F/3–4cm

T1/2was

significantlyenhanced

afterLSG

comparedwiththebaselin

e(25.3±4.4versus

11.8±3.0min

forliq

uids

and74.9±7.1versus

28.4±8.3min

forsolid

s,resp.,p<0 0

01).The

percentage

ofgastricretentionin

operated

patients

was

significantlylessthan

that

atbaselin

efor

liquids

at15,30,and60

min

(33.9±5.6,17.7±3.9,

and7.5±2.8%

versus

69.4±10.5,55.6±14.95,and

26.1±4.7%

,resp.,p

<0001),aswellasforsolid

sat

30,60,90,and

120min

(42.0±11.1,20.8±6.1,

11.0±5.9,and3.8±2.7%

versus

79.9±8.7,

67.4±12.2,37.0±10.9%,and

13.8±4.4%

,resp.,

p<0 0

01).

The

significant

acceleration

ofGEof

liquids

and

solid

safterLSGmay

have

contribu

tedto

weight

lossin

theim

mediatepo

stop

erativeperiod

(4–6

weeks).

Itremains

tobe

determ

ined

whether

theweight

losswill

continue

beyond

that

period

.

9Gastroenterology Research and Practice

Table2:Con

tinu

ed.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients(N

)Metho

dof

assessment/

follow-uppo

ints

Bou

giesize/distance

from

pylorus

Mainfind

ings

ofthestud

y

7Burgerhart,J.S.

etal.,2015

[24],

Netherlands

Prospective

stud

y20

Gastricem

ptying

stud

ywithsolid

andliq

uidmealcom

ponentsin

thesecond

year

afterLSG

34F/6cm

The

lagph

ase(solid)was

6.4±4.5min

ingrou

pI

and7.3±6.3ingrou

pII(p

=09

4);T

1/2(solid)w

as40.6±10.0miningrou

pIand

34.4±9.3ingrou

pII

(p=0 2

7);the

caloricem

ptying

ratewas

3.9

±0.6kcal/m

inin

grou

pIand3.9±1.0kcal/m

inin

grou

pII(p

=0 3

2).

Patientswithpo

stprandialsymptom

safterLSG

repo

rted

moresymptom

sdu

ring

thegastric

emptying

stud

ythan

didpatientswitho

utsymptom

s.How

ever,there

was

nodifference

betweengastricem

ptying

characteristicsbetween

both

grou

ps,suggestingthat

abno

rmalgastric

emptying

isno

tamajor

determ

inantof

postprandialsymptom

safterLSG.

8Melissas,J.etal.,

2013

[21],G

reece

Prospective

stud

y21

The

gastrictransittimes

were

stud

iedwithagammacamera

before

and4mon

ths

postop

eratively

34F/5cm

SGacceleratesthegastricem

ptying

ofsemisolids

9Pilo

ne,V

.etal.,

2013

[17],Italy

Prospective

controlled

rand

omized

stud

y

45Group

Aexam

before

(A1)

andaftertheop

eration(A

2).

Con

trol

grou

p(G

roup

B)

Gastricem

ptying

scintigraphy

1mon

thpreoperativelyand3

mon

thspo

stop

eratively

34Ch/4–5cm

The

scintigraphicstud

yshow

edaredu

cedhalf-life

tracer

(A1versus

A2:80.4±16.5min

versus

64.3±22

min

p=0 0

6),w

itho

utasignificant

difference.C

omparing

thetwogrou

ps,n

odifferencesoccurred

before

operation(B

versus

A1).T

hegastricem

ptying

timeresulted

ina

significant

redu

ctionin

grou

pA2rather

than

ingrou

psA1andB.

LSGredu

cesgastricem

ptying

time

10Michalsky,D

.etal.,

2013

[22],

Czech

Repub

lic

Prospective

rand

omized

stud

y12

Group

Aantrum

resection

Group

BAntrum

preservation

Gastricem

ptying

scintigraphy

before

and3mon

ths

postop

eratively

42F/7cm

Intheantrum

resectiongrou

p,theaveragetime

T1/2declined

from

57.5to

32.25min

(p=0 0

16)

andaverageretention%GEdrop

pedfrom

20.5to

9.5%

(p=0 0

73).

Intheantrum

resectiongrou

p,an

increase

ingastricem

ptying

postop

erativelywas

noted.

Com

plications

such

asfailu

reof

stom

ach

evacuation

wereno

tobserved

intheRAgrou

p;even

moreradicalresection

ofthepyloricantrum

performed

byLSGispo

ssiblewitho

utconcerns

ofpo

stop

erativedisorder

ofthestom

achevacuation

function

10 Gastroenterology Research and Practice

Table2:Con

tinu

ed.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients(N

)Metho

dof

assessment/

follow-uppo

ints

Bou

giesize/distance

from

pylorus

Mainfind

ings

ofthestud

y

11Parikh,

M.etal.,

2012

[25],U

SA

Datafrom

aninstitutional

review

board-

approved

electron

icregistry

62

Gastrod

uodenaltransittime

(antrum

todu

odenum

)was

calculated

from

apo

stop

erative

day1esop

hagram

.Postoperative

esop

hagram

s

40F/5–7cm

The

meangastrodu

odenaltransittimewas

12.3±19.8s.Alm

ostallp

atients(99%

)hada

transittimeof

lessthan

60s.

Nocorrelationwas

foun

dbetweengastrodu

odenal

transittimeand%EWLat

3,6,or

12mon

ths.

12Baumann,

T.etal.,

2011

[23],G

ermany

Prospective

pilot

stud

y5

MRI1daybefore

LSGand6days

and6mon

thsafterLSG

32F/5–6cm

The

dynamicanalysisshow

edthat

antral

prop

ulsive

peristalsiswas

preservedim

mediately

aftersurgeryanddu

ring

follow-up,

butfold

speed

increasedsignificantlyfrom

2.7mm/sbefore

LSG

to4.4mm/safter6mon

ths.The

sleeve

itself

remainedwitho

utrecognizableperistalsisin

three

patientsandshow

edon

lyun

coordinatedor

passive

motionin

twopatients.C

onsequ

ently,thefluid

transportthrou

ghthesleeve

was

markedlydelayed,

whereastheantrum

show

edacceleratedprop

ulsion

withtheem

ptying

half-timedecreasing

from

16.5min

preoperativelyto

7.9min

6mon

thsafter

surgery.

The

stom

achisfunction

allydividedinto

asleeve

witho

utprop

ulsive

peristalsisandan

accelerated

antrum

.Accelerated

emptying

seem

sto

becaused

byfaster

peristalticfolds.

13Pom

erri,F

.etal.,

2011

[18],Italy

Retrospective

stud

y57

The

size

ofthegastricfund

usremaining

afterLSGandgastric

voidingrate(fast/slow

)by

radiologicalup

per

gastrointestinalseries

(UGS)

with

awater-solub

lecontrastmedium

(CM).

NR/4–6

cm

Sleeve

voidingwas

fastin

49of

57patients

(85.96%)andslow

ineight(14.03%).

Patientsshow

ingarapidgastrodu

odenaltransitof

theCM

achieved

abetter

weightlossthan

patients

withaslow

voidingrate.

14Shah,S.etal.,

2010

[27],Ind

iaProspective

controlledstud

y

24werelean

controls(bod

ymassindex22.2±2.84

kg/m

(2)),20wereseverelyand

morbidlyobesepatientswith

T2D

Mwho

hadno

tun

dergon

eSG

(bod

ymass

index37.73±5.35

kg/m

(2)),

and23

wereseverelyand

morbidlyobesepatientswith

T2D

MafterSG

.

Scintigraphicim

agingwith

g-camera

NR

The

gastricem

ptying

half-timevalues

werealso

significantlyshorter(p

<05)in

thepo

st-SG

(52.8±13.5minutes)than

intheno

n-SG

(73.7±29.0minutes)andcontrol(72.8±29.6

minutes)grou

psdecreasedgastricem

ptying

half-timeafterSG

11Gastroenterology Research and Practice

Table2:Con

tinu

ed.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients(N

)Metho

dof

assessment/

follow-uppo

ints

Bou

giesize/distance

from

pylorus

Mainfind

ings

ofthestud

y

15Braghetto,I.etal.,

2009

[30],C

hile

Prospective

stud

y20

obesesubm

ittedto

LSG

18no

rmalsubjects

Gastricem

ptying

ofliq

uids

and

solid

swas

measuredby

scintigraphictechniqu

e3mon

ths

postop

eratively.

32F/2cm

Inthegrou

pof

operated

patients,70%

ofthem

(n=14)presentedacceleratedem

ptying

forliq

uids

and75%(n

=15)forsolid

scomparedto

22.2%and

27.7%,respectively,in

thecontrolgroup

.The

half-timeof

gastricem

ptying

(T(1/2))in

patients

subm

ittedto

SGboth

forliq

uids

andsolid

swere

significantlymoreacceleratedcomparedto

the

controlgroup

(34.9±24.6versus

13.6±11.9min

forliq

uids

and78

±15.01versus

38.3±18.77min

forsolid

s;p<0 0

1).T

hegastricem

ptying

for

liquids

expressedas

thepercentagesof

retentionat

20,30,and60

min

were30.0±0.25%,15.4±0.18%,

and5.7±0.10%,respectively,in

operated

patients,

significantlylessthan

thecontrolsub

jects

(p<0 0

01).Fo

rsolid

s,thepercentage

ofretention

at60,90,and120minwas56

+/−

28%,34+/−

22%,

and12

+/−

8%,respectively,forcontrols,w

hileit

was

25.3+/−

0.20%,9

+/−

0.12%,and

3+/−

0.05%,

respectively,inop

erated

patients(p

<001).

Gastricem

ptying

afterSG

isacceleratedeither

forliq

uids

aswellasforsolid

sin

themajority

ofpatients.

16Bernstine

Hetal.,

2009

[31],Israel

Prospective

stud

y21

Gastricem

ptying

scintigraphy

ofsemisolidswas

performed

before

and3mon

thsafterLSG

48F/6cm

The

meanT1/2rawdata

were62.39±19.83and

56.79±18.72min

(p=036,t

=−0

92,N

S)before

and3mon

thsafterLSG,respectively.The

T1/2

linearwas

103.64

±9.82

and106.92

±14.55,

(p=0 4

3,t=

−043,N

S),and

thelin

earfitslop

e0.48

±0.04

and0.47

±0.05

(p=0 4

8,t=

07,N

S).

LSGwithantrum

preservation

asperformed

inthis

series

hasno

effecton

gastricem

ptying.

17Melissas,J.etal.,

2008

[20],G

reece

Prospective

stud

y14

Ninepatientsun

derw

entgastric

emptying

stud

ies,using

radioisotopictechniqu

ebefore,6

mon

ths,and24

mon

thsafterthe

operation.

The

remaining

five

patientsun

derw

entgastric

emptying

stud

ies,6mon

thsand

24mon

thsaftertheop

eration.

Scintigraphicim

agingwas

performed

withaγ-camera

NR

Inthenine

patientswho

underw

entgastric

emptying

stud

iespreoperativelyand6and24

mon

thspo

stop

eratively,theT-lag

phasedu

ration

significantlydecreased,

followingtheSG

,from

17.30(range

15.50–20.90)

min,to12.50(range

9.20–18.00)min

at6mon

thsand12.16(range

10.90–20.00)

min

at24

mon

thspo

stop

eratively

(p<005)

The

gastricem

ptying

halftime(T1/2)

accelerated

significantlypo

stop

erativelyfrom

86.50(range

77.50–104.60)min,to62.50(range

46.30–80.00)

12 Gastroenterology Research and Practice

Table2:Con

tinu

ed.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients(N

)Metho

dof

assessment/

follow-uppo

ints

Bou

giesize/distance

from

pylorus

Mainfind

ings

ofthestud

y

min

at6mon

thsand60.80(range

54.80–100.00)

min

at24

mon

thsafterSG

(p<0 0

5).T

hepercentage

ofgastricem

ptying

(%GE)increased

significantlypo

stop

eratively,from

52(range

43–58)

%to

72(range

57–97)

%at

6mon

thsand

74(range

45–82)

%at

24mon

ths,followingSG

(P<0 0

5).N

odifferencesin

gastricem

ptying

were

observed,w

henvalues

at24

mon

thswere

comparedto

thoseat

6mon

thspo

stop

eratively.

Whenthewho

legrou

pof

14patientswas

stud

ied,

therewerealso

nosignificant

changesin

T-lag,

T1/2and%GEbetween6and24

mon

ths

postop

eratively.

Con

stanteffectof

SGin

theacceleration

ofgastric

emptying

ofsolid

s,which

occursfaster,not

onlyin

shortbu

talso

inlong-term

postop

eratively

18Melissas,J.etal.,

2007

[19],G

reece

Prospective

stud

y23

The

scintigraphicmeasurement

ofthegastricem

ptying

ofasolid

mealp

reop

erativelyand6

mon

thspo

stop

eratively.

Gastricem

ptying

stud

iesusing

radioisotopictechniqu

ebefore

and6mon

thsaftertheop

eration.

34F/7cm

Alth

ough

themealsizewas

drastically

redu

ced,the

mealfrequ

ency

increasedpo

stop

erativelyin

12patients(52.2%

).Only5patients(21.8%

)repo

rted

occasion

alvomitingaftermealsfollowingSG

.The

gastric

emptying

half-time(T1/2)

accelerated(47.6±23.2

versus

94.3±15.4,p

<0 0

1),and

theT-lag

phase

duration

decreased(9.5±2

min

versus

19.2±2min,p

<005)po

stop

eratively.The

percentage

ofthemealemptiedfrom

thestom

ach

90min

afterconsum

ptionincreasedsignificantly

afterSG

(75.4±14.9%

versus

49.2±8.7%

,p<001);thestom

achem

ptiesitscontentsrapidly

into

thesm

allintestine

andsymptom

sof

vomiting

aftereating

(characteristicof

restrictive

procedures)areeither

absent

orvery

mild

NR:n

otrepo

rted.

13Gastroenterology Research and Practice

Table3:Stud

iesassessingbowelmotility.

Autho

r,year

ofpu

blication,

coun

try

Typeof

stud

yPatients(N

)Metho

dof

assessment

Stud

ymainfind

ing

1Trung,V

.N.etal.,

2013

[32],Japan

Prospective

stud

y12

Intestinalmotility

during

OGTTwas

assessed

usingcine

MRIbefore

and3mon

ths

postop

eratively

LSGleadsto

acceleratedintestinalmotility

and

redu

cedintestinaltransittime

2Melissas,J.etal.,

2013

[21],G

reece

Prospective

stud

y21

g-Cam

erabefore

and4mon

thspo

stop

eratively

LSGacceleratesthesm

allb

oweltransitof

semisolids.In

addition

,itdelays

theinitiation

ofcecalfi

lling

andTICVt.

3Shah,S.etal.,

2010

[27],Ind

iaProspective

controlledstud

y

67Con

trols:24

MorbidlyobesepatientswithT2D

Mno

tun

dergon

eSG

:20

MorbidlyobesepatientswithT2D

MafterSG

:23

Scintigraphicim

aging

Decreased

smallb

oweltransittimeafterSG

14 Gastroenterology Research and Practice

of the normal gastric pacemaker during LSG had as a resultthe acute gastric slow-wave quiescence or the generation ofdistal ectopic pacemakers accompanied by a markedlyincreased propagation velocity. It seems that the sleeve affectsthe electrophysiology of the stomach. Further studies areneeded to support this.

There was a consensus except for one study that gastricemptying was accelerated. The rapid gastric emptying wasalso strengthened by the observation of our team that asignificant proportion of patients experienced dumpingsyndrome upon provocation at six weeks and 6 and 12months after LSG. These symptoms included both earlyand late symptoms suggesting that LSG may lead tochanges in eating patterns after LSG, especially in sweeters[37, 38]. Only one study showed no effect on gastricemptying. In this study, the follow-up was done in 3months, and the created sleeve was performed using abougie 48F at a distance of 6 cm from the pylorus [31].Therefore, the sleeve might be large enough withoutincreasing its intraluminal pressure.

There is still a debate concerning the maintenance ofthe antrum in order to avoid interference with the gastricphysiology or its resection to increase the restrictive mech-anism. Abdallah et al., who compared groups with resec-tions at 2 cm versus 6 cm distances from the pylorus,showed that there was statistically significant excess weightloss between the groups, concluding that increasing the sizeof the resected antrum was associated with better weightloss, without increasing significantly the rate of complica-tions [39]. Similarly, Obeidat et al. showed that patientswith resection at 2 cm distance from the pylorus experi-enced statistically significant better maintained weight lossthan did patients with resection at 6 cm [40]. On the con-trary, ElGeidie et al. found no statistical differences regard-ing weight loss at the groups at 2 cm and 6 cm from thepylorus [41]. Vives et al. showed that gastric emptyingwas faster in the group with the resection at 3 cm fromthe pylorus compared to that at 8 cm from the pylorus at6 and 12 months postoperatively [14]. Unlike the previous,Fallahat et al. compared the gastric emptying in patients at4 cm and 7 cm distance from pylorus 3 months postopera-tively. The authors showed that resection at 4 cm fromthe pylorus were associated with delayed gastric emptying,and resection at 7 cm from the pylorus, with acceleratedgastric emptying. The authors speculated that resection at4 cm from the pylorus had as a consequence neural inner-vations of the antrum being abolished, contributing toslower emptying. These patients experienced nausea, vomit-ing, and poor appetite. On the other hand, the resectionat 7 cm from the pylorus preserved the contractility ofthe antrum, leading to rapid gastric emptying due to theabsence of redistribution process since the body and funduswere excised. These patients complained of dumping-likesymptoms and had more frequent meals [42]. Furtherprospective randomized trials are needed to compare themotility changes and clinical symptoms in patients with thepreservation or not of antrum.

There is scant information concerning the possibleexplanation of how these motility alterations may affect

clinical symptoms or explain the underlying mechanisms ofaction. It seems that the technique is not standardized, anddifferent sleeves are created. Thus, different residual gastricvolumes are produced. Since now, no clear association wasfound between gastric volume and weight loss. Researcherssuggest that the physiological changes and not the size ofthe sleeve are responsible as mechanisms of action. What isknown is that LSG changes the profile of gut hormones. Sistaet al. showed that the rapid gastric emptying was correlatedwith the increased production of GLP-1 in the distal bowel[16]. Burgerhart et al. associated postprandial symptomswith gastric emptying. No difference on gastric-emptyingcharacteristics was found between patients with low orhigh postprandial symptoms [24]. Pomerri et al. foundthat patients presenting with a rapid gastroduodenal transitexperienced better weight loss than patients presenting witha slow voiding rate [18]. It seems that little is known regard-ing the underlining mechanisms by which LSG controlsappetite and food intake. Since the data are restricted tomedium term, it would be interesting to see if the sleevebehaves differently in the long term and how weight regainis explained in some patients.

Bowel motility was the least studied. It seems that thefood reaches the terminal ileum faster but arrives at thececum later. Thus, the contact of the food with the area of ter-minal ileum is extended. Perhaps, this altered interaction offood with the gastrointestinal tract may be a key componentto explain the neurohormonal changes via the stimulation ofintestinal L cells producing incretions and understandingthe underlining mechanisms which improve the metabolicprofile of the patients.

The limitations of the review include the lack ofstandardization of the surgical technique, the differentfollow-up timings, the different measured outcomes, thesmall sample siz,e and the lack of available long-term databeyond four years.

Further pathophysiological studies are needed to inves-tigate the exact correlation of the motility parameters withthe clinical symptoms and gut peptide alterations andpotential hormonal interactions between gastrointestinaltract and brain.

5. Conclusion

Laparoscopic sleeve gastrectomy has impacts on the gastro-intestinal motility. The data remain debatable for esophagealmotility. The stomach and small bowel motilities wereaccelerated, while the initiation of cecal filling and theileocecal valve transit was delayed. Further pathophysiologi-cal studies are needed to investigate the exact correlation ofthe motility parameters with the clinical symptoms and gutpeptide alterations.

Conflicts of Interest

The authors declare that there is no conflict of interestregarding the publication of this article.

15Gastroenterology Research and Practice

References

[1] L. Angrisani, A. Santonicola, P. Iovino et al., “Bariatric surgeryand endoluminal procedures: IFSO worldwide survey 2014,”Obesity Surgery, vol. 27, no. 9, pp. 2279–2289, 2017.

[2] M. M. Hutter, B. D. Schirmer, D. B. Jones et al., “First reportfrom the American College of Surgeons Bariatric Surgery Cen-ter Network: laparoscopic sleeve gastrectomy has morbidityand effectiveness positioned between the band and thebypass,” Annals of Surgery, vol. 254, no. 3, pp. 410–422, 2011.

[3] S. H. Chang, C. R. Stoll, J. Song, J. E. Varela, C. J. Eagon, andG. A. Colditz, “The effectiveness and risks of bariatric surgery:an updated systematic review and meta-analysis, 2003-2012,”JAMA Surgery, vol. 149, no. 3, pp. 275–287, 2014.

[4] R. T. Yehoshua, L. A. Eidelman, M. Stein et al., “Laparoscopicsleeve gastrectomy—volume and pressure assessment,” Obe-sity Surgery, vol. 18, no. 9, pp. 1083–1088, 2008.

[5] E. Sioka, G. Tzovaras, F. Tsiopoulos et al., “Esophageal motilityafter laparoscopic sleeve gastrectomy,” Clinical and Experi-mental Gastroenterology, vol. 10, pp. 187–194, 2017.

[6] E. Kleidi, D. Theodorou, K. Albanopoulos et al., “The effect oflaparoscopic sleeve gastrectomy on the antireflux mechanism:can it be minimized?,” Surgical Endoscopy, vol. 27, no. 12,pp. 4625–4630, 2013.

[7] F. Mion, S. Tolone, A. Garros et al., “High-resolutionimpedance manometry after sleeve gastrectomy: increasedintragastric pressure and reflux are frequent events,” ObesitySurgery, vol. 26, no. 10, pp. 2449–2456, 2016.

[8] F. Rebecchi, M. E. Allaix, C. Giaccone, E. Ugliono, G. Scozzari,and M. Morino, “Gastroesophageal reflux disease and laparo-scopic sleeve gastrectomy: a physiopathologic evaluation,”Annals of Surgery, vol. 260, no. 5, pp. 909–915, 2014.

[9] G. Del Genio, S. Tolone, P. Limongelli et al., “Sleeve gastrec-tomy and development of “de novo” gastroesophageal reflux,”Obesity Surgery, vol. 24, no. 1, pp. 71–77, 2014.

[10] V. Gorodner, R. Buxhoeveden, G. Clemente, L. Solé, L. Caro,and A. Grigaites, “Does laparoscopic sleeve gastrectomy haveany influence on gastroesophageal reflux disease? Prelimi-nary results,” Surgical Endoscopy, vol. 29, no. 7, pp. 1760–1768, 2015.

[11] J. S. Burgerhart, C. A. Schotborgh, E. J. Schoon et al.,“Effect of sleeve gastrectomy on gastroesophageal reflux,”Obesity Surgery, vol. 24, no. 9, pp. 1436–1441, 2014.

[12] W. V. Petersen, T. Meile, M. A. Küper, M. Zdichavsky,A. Königsrainer, and J. H. Schneider, “Functional importanceof laparoscopic sleeve gastrectomy for the lower esophagealsphincter in patients with morbid obesity,” Obesity Surgery,vol. 22, no. 3, pp. 360–366, 2012.

[13] I. Braghetto, E. Lanzarini, O. Korn, H. Valladares, J. C. Molina,and A. Henriquez, “Manometric changes of the loweresophageal sphincter after sleeve gastrectomy in obesepatients,” Obesity Surgery, vol. 20, no. 3, pp. 357–362, 2010.

[14] M. Vives, A. Molina, M. Danús et al., “Analysis of gastricphysiology after laparoscopic sleeve gastrectomy (LSG) withor without antral preservation in relation to metabolicresponse: a randomised study,” Obesity Surgery, vol. 27,no. 11, pp. 2836–2844, 2017.

[15] E. Mans, M. Serra-Prat, E. Palomera, X. Suñol, and P. Clavé,“Sleeve gastrectomy effects on hunger, satiation, and gastroin-testinal hormone and motility responses after a liquid mealtest,” The American Journal of Clinical Nutrition, vol. 102,no. 3, pp. 540–547, 2015.

[16] F. Sista, V. Abruzzese, M. Clementi, S. Carandina, M. Cecilia,and G. Amicucci, “The effect of sleeve gastrectomy on GLP-1secretion and gastric emptying: a prospective study,” Surgeryfor Obesity and Related Diseases, vol. 13, no. 1, pp. 7–14, 2017.

[17] V. Pilone, S. Tramontano, R. Di Micco et al., “Gastric empty-ing after sleeve gastrectomy: statistical evidence of a controlledprospective study with gastric scintigraphy,” Minerva Chirur-gica, vol. 68, no. 4, pp. 385–392, 2013.

[18] F. Pomerri, M. Foletto, G. Allegro, P. Bernante, L. Prevedello,and P. C. Muzzio, “Laparoscopic sleeve gastrectomy–radiological assessment of fundus size and sleeve voiding,”Obesity Surgery, vol. 21, no. 7, pp. 858–863, 2011.

[19] J. Melissas, S. Koukouraki, J. Askoxylakis et al., “Sleeve gastrec-tomy: a restrictive procedure?,” Obesity Surgery, vol. 17, no. 1,pp. 57–62, 2007.

[20] J. Melissas, M. Daskalakis, S. Koukouraki et al., “Sleevegastrectomy-a “food limiting” operation,” Obesity Surgery,vol. 18, no. 10, pp. 1251–1256, 2008.

[21] J. Melissas, A. Leventi, I. Klinaki et al., “Alterations of globalgastrointestinal motility after sleeve gastrectomy: a prospectivestudy,” Annals of Surgery, vol. 258, no. 6, pp. 976–982, 2013.

[22] D. Michalsky, P. Dvorak, J. Belacek, and M. Kasalicky,“Radical resection of the pyloric antrum and its effect ongastric emptying after sleeve gastrectomy,” Obesity Surgery,vol. 23, no. 4, pp. 567–573, 2013.

[23] T. Baumann, S. Kuesters, J. Grueneberger et al., “Time-resolvedMRI after ingestion of liquids reveals motility changesafter laparoscopic sleeve gastrectomy–preliminary results,”Obesity Surgery, vol. 21, no. 1, pp. 95–101, 2011.

[24] J. S. Burgerhart, P. W. van Rutte, M. A. Edelbroek et al.,“Association between postprandial symptoms and gastricemptying after sleeve gastrectomy,” Obesity Surgery, vol. 25,no. 2, pp. 209–214, 2015.

[25] M. Parikh, J. Eisner, N. Hindman, E. Balthazar, and J. K.Saunders, “Tests of correlation between immediate postopera-tive gastroduodenal transit times and weight loss after laparo-scopic sleeve gastrectomy,” Surgical Endoscopy, vol. 26, no. 12,pp. 3548–3551, 2012.

[26] B. Vigneshwaran, A. Wahal, S. Aggarwal et al., “Impact ofsleeve gastrectomy on type 2 diabetes mellitus, gastric empty-ing time, glucagon-like peptide 1 (GLP-1), ghrelin and leptinin non-morbidly obese subjects with BMI 30-35.0 kg/m2: aprospective study,” Obesity Surgery, vol. 26, no. 12, pp. 2817–2823, 2016.

[27] S. Shah, P. Shah, J. Todkar, M. Gagner, S. Sonar, and S. Solav,“Prospective controlled study of effect of laparoscopic sleevegastrectomy on small bowel transit time and gastric emptyinghalf-time in morbidly obese patients with type 2 diabetesmellitus,” Surgery for Obesity and Related Diseases, vol. 6,no. 2, pp. 152–157, 2010.

[28] R. Berry, L. K. Cheng, P. Du et al., “Patterns of abnormalgastric pacemaking after sleeve gastrectomy defined bylaparoscopic high-resolution electrical mapping,” ObesitySurgery, vol. 27, no. 8, pp. 1929–1937, 2017.

[29] A. A. Kandeel, M. D. Sarhan, T. Hegazy, M. M. Mahmoud, andM. H. Ali, “Comparative assessment of gastric emptying inobese patients before and after laparoscopic sleeve gastrectomyusing radionuclide scintigraphy,” Nuclear Medicine Commu-nications, vol. 36, no. 8, pp. 854–862, 2015.

[30] I. Braghetto, C. Davanzo, O. Korn et al., “Scintigraphic evalu-ation of gastric emptying in obese patients submitted to sleeve

16 Gastroenterology Research and Practice

gastrectomy compared to normal subjects,” Obesity Surgery,vol. 19, no. 11, pp. 1515–1521, 2009.

[31] H. Bernstine, R. Tzioni-Yehoshua, D. Groshar et al., “Gastricemptying is not affected by sleeve gastrectomy–scintigraphicevaluation of gastric emptying after sleeve gastrectomy with-out removal of the gastric antrum,” Obesity Surgery, vol. 19,no. 3, pp. 293–298, 2009.

[32] V. N. Trung, H. Yamamoto, A. Furukawa et al., “Enhancedintestinal motility during oral glucose tolerance test afterlaparoscopic sleeve gastrectomy: preliminary results using cinemagnetic resonance imaging,” PLoS One, vol. 8, no. 6, articlee65739, 2013.

[33] M. Gagner, M. Deitel, T. L. Kalberer, A. L. Erickson, and R. D.Crosby, “The Second International Consensus Summit forSleeve Gastrectomy, March 19-21, 2009,” Surgery for Obesityand Related Diseases, vol. 5, no. 4, pp. 476–485, 2009.

[34] P. Prinz and A. Stengel, “Control of food intake by gastrointes-tinal peptides: mechanisms of action and possible modulationin the treatment of obesity,” Journal of Neurogastroenterologyand Motility, vol. 23, no. 2, pp. 180–196, 2017.

[35] A. Inui, A. Asakawa, C. Y. Bowers et al., “Ghrelin, appetite, andgastric motility: the emerging role of the stomach as anendocrine organ,” The FASEB Journal, vol. 18, no. 3,pp. 439–456, 2004.

[36] P. Janssen, P. Vanden Berghe, S. Verschueren, A. Lehmann,I. Depoortere, and J. Tack, “Review article: the role of gastricmotility in the control of food intake,” Alimentary Pharmacol-ogy & Therapeutics, vol. 33, no. 8, pp. 880–894, 2011.

[37] G. Tzovaras, D. Papamargaritis, E. Sioka et al., “Symptomssuggestive of dumping syndrome after provocation in patientsafter laparoscopic sleeve gastrectomy,”Obesity Surgery, vol. 22,no. 1, pp. 23–28, 2012.

[38] D. Papamargaritis, G. Koukoulis, E. Sioka et al., “Dumpingsymptoms and incidence of hypoglycaemia after provocationtest at 6 and 12 months after laparoscopic sleeve gastrectomy,”Obesity Surgery, vol. 22, no. 10, pp. 1600–1606, 2012.

[39] E. Abdallah, A. El Nakeeb, T. Youssef et al., “Impact of extentof antral resection on surgical outcomes of sleeve gastrectomyfor morbid obesity (a prospective randomized study),” ObesitySurgery, vol. 24, no. 10, pp. 1587–1594, 2014, Erratum in: ObesSurg. 2015 Oct;25(10):1987. Yousef, Tamer [Corrected toYoussef, Tamer].

[40] F. Obeidat, H. Shanti, A. Mismar, N. Albsoul, andM. Al-Qudah, “The magnitude of antral resection in laparo-scopic sleeve gastrectomy and its relationship to excess weightloss,” Obesity Surgery, vol. 25, no. 10, pp. 1928–1932, 2015.

[41] A. ElGeidie, M. ElHemaly, E. Hamdy, M. El Sorogy,M. AbdelGawad, and N. GadElHak, “The effect of residualgastric antrum size on the outcome of laparoscopic sleeve gas-trectomy: a prospective randomized trial,” Surgery for Obesityand Related Diseases, vol. 11, no. 5, pp. 997–1003, 2015.

[42] B. Fallatah, A. AzizShehry, L. Abdelsamad, H. Zaid,S. Hussain, and S. Jaber, “Comparison study of gastric empty-ing after performing sleeve gastrectomy with two differenttechniques,” Journal of Surgery, vol. 1, no. 4, pp. 53–56, 2013.

17Gastroenterology Research and Practice

Stem Cells International

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

MEDIATORSINFLAMMATION

of

EndocrinologyInternational Journal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Disease Markers

Hindawiwww.hindawi.com Volume 2018

BioMed Research International

OncologyJournal of

Hindawiwww.hindawi.com Volume 2013

Hindawiwww.hindawi.com Volume 2018

Oxidative Medicine and Cellular Longevity

Hindawiwww.hindawi.com Volume 2018

PPAR Research

Hindawi Publishing Corporation http://www.hindawi.com Volume 2013Hindawiwww.hindawi.com

The Scientific World Journal

Volume 2018

Immunology ResearchHindawiwww.hindawi.com Volume 2018

Journal of

ObesityJournal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Computational and Mathematical Methods in Medicine

Hindawiwww.hindawi.com Volume 2018

Behavioural Neurology

OphthalmologyJournal of

Hindawiwww.hindawi.com Volume 2018

Diabetes ResearchJournal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Research and TreatmentAIDS

Hindawiwww.hindawi.com Volume 2018

Gastroenterology Research and Practice

Hindawiwww.hindawi.com Volume 2018

Parkinson’s Disease

Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwww.hindawi.com

Submit your manuscripts atwww.hindawi.com