Table of Contents Author Guidelines Submit a Manuscript
Gastroenterology Research and Practice
Volume 2018, Article ID 4135813, 17 pages
https://doi.org/10.1155/2018/4135813
Review Article

Impact of Laparoscopic Sleeve Gastrectomy on Gastrointestinal Motility

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

Correspondence should be addressed to Dimitris Zacharoulis; moc.oohay@midahcaz

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.

Abstract

Objective. Laparoscopic sleeve gastrectomy (LSG) was considered mainly as a restrictive procedure due to anatomic alterations in the upper gastrointestinal tract. Additionally, due to neurohormonal alterations, LSG modifies the gastrointestinal motility, which controls appetite and feeling of satiety. Aim. The aim of the study was to review the impact of laparoscopic sleeve gastrectomy on gastrointestinal motility. Material and Methods. A search of the medical literature was undertaken in Pubmed, Web of Science, and Cochrane 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 distance from pylorus. The stomach motility was assessed in eighteen studies. Functionally, the sleeve was divided into a passive sleeve and an accelerated antrum. All scintigraphic studies revealed accelerated gastric emptying after LSG except of one. Patients demonstrated a rapid gastroduodenal transit time. The resection of the gastric pacemaker had as a consequence aberrant distal ectopic pacemaking or bioelectrical quiescence after LSG. The bowel motility was the least studied. Small bowel transit time was reduced; opposite to that the initiation of cecal filling and the ileocecal valve transit was delayed. Conclusion. Laparoscopic sleeve gastrectomy has impacts on gastrointestinal motility. The data remain debatable for esophageal motility. Stomach and small bowel motility were accelerated, while the initiation of cecal filling and the ileocecal valve transit was delayed. Further pathophysiological studies are needed to evaluate the correlation of motility data with clinical symptoms.

1. Introduction

Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed procedure in the world and has overtaken the “gold standard” Roux-en-Y gastric bypass (RYGB), which remains the most performed bariatric/metabolic procedure only in Latin/South America. The trend analysis demonstrated that LSG had the largest average annual percentage increase of approximately 9% from 2013 of the worldwide bariatric/metabolic surgical procedures [1]. Laparoscopic sleeve gastrectomy is positioned between the adjustable gastric banding and RYGB in terms of morbidity with effectiveness comparable to RYGB even at five years [2, 3].

Laparoscopic sleeve gastrectomy involves the removal of the gastric fundus and greater curvature portion of the stomach, leaving only a lesser curvature tube. Yehoshua et al. showed that after the sleeve, the fundus, which is the most distensible part of the stomach, is removed, thus leaving a sleeve which is characterized by markedly lesser distensibility and high intraluminal pressure, leading to the feeling of early satiety [4]. The abstraction of the fundus is related to physiological alterations in the upper gastrointestinal tract, since the angle of His and the receptive relaxation mechanism is abolished, and the gastric pacemaker is abandoned. Furthermore, the antrum is preserved in some cases depending on the distance of the resection, and the pylorus remains intact. These physiological changes are expected to provoke motility alterations at the gastrointestinal tract.

The aim of the study was to review the impact of laparoscopic sleeve gastrectomy on gastrointestinal motility.

2. Material and Methods

2.1. Search Strategy

A search of the medical literature was undertaken in Pubmed, Web of Science, and Cochrane library until August 2017. The keywords used were “sleeve gastrectomy” AND (motility OR gastrointestinal motility OR esophageal motility OR gastric motility OR bowel motility OR emptying OR manometry).

2.2. Eligibility Criteria
2.2.1. Types of Studies

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

2.2.2. Types of Participants

The types of participants were obese patients () undergoing laparoscopic sleeve gastrectomy.

2.2.3. Types of Outcome Measures

The outcomes measured were esophageal, gastric, and bowel motility.

2.3. Inclusion and Exclusion Criteria

Two independent reviewers (Eleni Sioka and Konstantinos Perivoliotis) screened abstracts, reviewed full text versions of all studies classified, and extracted data. Any trial considered relevant was retrieved for further review. The full texts were independently assessed by two reviewers. Disagreements were resolved with a third reviewer. Only published articles in the English language were included. Meta-analysis, systematic reviews, letters to the editor, case studies, non-English language publications, duplicate studies, experimental studies, and conference papers were excluded.

2.4. Data Extraction and Quality Assessment

One reviewer (Konstantinos Perivoliotis) extracted data from selected trials and 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 collected were first author, year of publication, country, type of study, number of participants, method of assessment, timing points, and main findings.

3. Results

3.1. Study Selection

One hundred seventy eight studies were screened for eligibility and fifty two studies assessed in full text. Twenty four studies were excluded due to various reasons. Finally, 28 studies were eligible to be included in the review (Figure 1). There was complete agreement among the authors as to the inclusion of these studies.

Figure 1: Flow diagram.
3.2. Esophageal Motility

Nine studies assessed esophageal motility. Two studies were conducted in Greece [5, 6], one in 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 50 months. The bougie size ranged from 32 to 40F. The distance from the pylorus ranged from 2 to 6 cm. The lower esophageal sphincter (LES) length was reduced in three studies [5, 9, 13] increased in two studies [6, 10], and unchanged in one study [8]. The LES resting pressure decreased in four studies [5, 10, 11, 13], increased in two studies [6, 12], and remained unchanged in two studies [8, 9]. The amplitude pressure was reduced in two studies [5, 11], increased in one study [10], and unchanged in one study [8]. Amplitude pressure decreased in distal esophagus and increased in the other parts in one study [6]. Ineffective motility was reported in four studies. The percentage was increased from 10% to 45% postoperatively in one study [9], while it was the same preoperatively (7%) in another study [10], was increased at 5% (1/20 patients) in one study [11], and was reported at 37.7% (20/53 patients) in another study [7]. The percentage of normal peristaltic contractions was not affected in one study [11], while it increased in another study [5]. The summary of studies is reported in Table 1.

Table 1: Studies assessing esophageal motility.
3.3. Stomach Motility

Eighteen studies assessed stomach motility. Eleven studies were conducted in Europe (Spain [] [14, 15], Italy [] [1618], Greece [] [1921], Czech Republic [] [22], Germany [] [23], and the Netherlands [] [24]), whereas one study was performed in the USA [25], two studies in India [26, 27], one study in New Zealand [28], one in Egypt [29], one in Chile [30], and one in Israel [31]. Twelve studies were prospective studies, four studies were prospective randomized controlled studies [14, 17, 22, 27], and two were retrospective studies [18, 25]. The method of gastric emptying assessment was gastric scintigraphic studies in fourteen studies and magnetic resonance imaging (MRI) in one study [23], while one study assessed the gastric slow-wave pacemaking using laparoscopic high-resolution (HR) electrical mapping [28], and two studies assessed the gastroduodenal transit time by radiological upper gastrointestinal series [18, 25].

The postoperative follow-up ranged from 3 to 24 months. The bougie size ranged from 32 to 48F. The distance from the pylorus ranged from 2 to 8 cm. All studies showed accelerated gastric emptying after LSG except for one [31]. Functionally, the sleeve was divided into a passive sleeve and an accelerated antrum. The patients demonstrated a rapid gastroduodenal transit time. The resection of the gastric pacemaker had as a consequence aberrant distal ectopic pacemaking or bioelectrical quiescence after LSG. No correlation was observed between gastric emptying and postprandial symptoms in one study. No correlation was found between gastroduodenal transit time and weight loss in one study [25], while in another study, patients showing a rapid gastroduodenal transit had better weight loss than patients presenting with a slow voiding rate [18]. The summary of the studies are presented in Table 2.

Table 2: Studies assessing stomach motility.
3.4. Bowel Motility

Three studies assessed the bowel motility. Two were prospective studies and one was prospective randomized study. One study was conducted in Japan, one in Greece, and one in India [21, 27, 32]. Trung et al. evaluated the intestinal motility using cine MRI preoperatively and 3 months postoperatively and found reduced intestinal transit time leading to accelerated intestinal motility [32]. Melissas et al. evaluated prospectively 21 patients preoperatively with a g-camera and 4 months postoperatively. Apart from the acceleration of small bowel transit time, the authors showed that initiation of cecal filling and the ileocecal valve transit was delayed [21]. Similarly, Shah et al. showed decreased small bowel transit time after LSG [27] (Table 3).

Table 3: Studies assessing bowel motility.

4. Discussion

The aim of this study was to review the impact of laparoscopic sleeve gastrectomy on gastrointestinal motility. The gastrointestinal motility research might be essential to recognize the behavior of the created sleeve, to explain possible clinical symptoms-implications, and to elucidate possible mechanisms of actions of this procedure. According to the Second International Consensus Summit for Sleeve Gastrectomy, the panel of experts voted the following as mechanisms of 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 studies assessing hormonal alterations after LSG. Concerning hormonal changes, it seems that patients experienced a pronounced and long-lasting decrease of circulating ghrelin and increased postprandial release of the CCK, GLP-1, and PYY, the so-called gut peptides after LSG. It was hypothesized that the faster delivery of nutrients to the distal intestinal tract postoperatively may provoke increased the postprandial release of the gut peptides contributing to the improvement of glucose control as well as to the reduction of 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 outcomes of esophageal motility may be attributable to the timing of postoperative follow-up, the variability of surgical techniques, the different bougie sizes, and the different dissections from pylorus, thus creating a sleeve with variable distensibility and intraluminal pressure with, in part, the preservation of the antrum. The percentage of peristaltic normal contractions increased postoperatively and is not statistically significant at 3 months [11] but statistically significant later [5]. It seems that the motility of the body of the esophagus was normalized. Perhaps, this might be attributable to the reduced intrabdominal pressure due to weight loss. An increase in the esophageal acidification was reported in few studies [9, 11]. Del Genio et al. pointed out a decrease in the esophageal transit after LSG in impedance study. Furthermore, the authors explained the reflux episodes as a consequence of retrograde movements into the esophagus [9].

Gastric motility emerges as the role of the stomach as an endocrine organ. Gastric motility acts as a central mediator of hunger, satiation, and satiety. Gastric emptying plays a key role in regulating food intake. Gastric distention acts a satiety signal to inhibit food intake [35]. During food intake, it is the gastric distention and gastric accommodation that regulate satiation in a manner. After food intake, when the stomach empties gradually, it is the gastric emptying and the intestinal exposure of the nutrients that play a key role, while the role of gastric distention follows. It seems that gastric accommodation and gastric emptying are implicated in the regulation of gastric distention and intestinal exposure of nutrients, thus control satiation and satiety. The correlations between gastric accommodation, gastric emptying, and body weight suggest that gastric motility may also affect the long-term regulation of body weight [36].

A number of studies assessed gastric motility. Baumann et al. showed that the sleeve was completely motionless without any coordinate peristalsis, while the antrum had faster peristaltic folds, concluding that gastric emptying is directly linked to the function of the antrum when the antrum is preserved in LSG [23]. It seems that the resection of the normal gastric pacemaker during LSG had as a result the acute gastric slow-wave quiescence or the generation of distal ectopic pacemakers accompanied by a markedly increased propagation velocity. It seems that the sleeve affects the electrophysiology of the stomach. Further studies are needed to support this.

There was a consensus except for one study that gastric emptying was accelerated. The rapid gastric emptying was also strengthened by the observation of our team that a significant proportion of patients experienced dumping syndrome upon provocation at six weeks and 6 and 12 months after LSG. These symptoms included both early and late symptoms suggesting that LSG may lead to changes in eating patterns after LSG, especially in sweeters [37, 38]. Only one study showed no effect on gastric emptying. In this study, the follow-up was done in 3 months, and the created sleeve was performed using a bougie 48F at a distance of 6 cm from the pylorus [31]. Therefore, the sleeve might be large enough without increasing its intraluminal pressure.

There is still a debate concerning the maintenance of the antrum in order to avoid interference with the gastric physiology or its resection to increase the restrictive mechanism. Abdallah et al., who compared groups with resections at 2 cm versus 6 cm distances from the pylorus, showed that there was statistically significant excess weight loss between the groups, concluding that increasing the size of the resected antrum was associated with better weight loss, without increasing significantly the rate of complications [39]. Similarly, Obeidat et al. showed that patients with resection at 2 cm distance from the pylorus experienced statistically significant better maintained weight loss than did patients with resection at 6 cm [40]. On the contrary, ElGeidie et al. found no statistical differences regarding weight loss at the groups at 2 cm and 6 cm from the pylorus [41]. Vives et al. showed that gastric emptying was faster in the group with the resection at 3 cm from the pylorus compared to that at 8 cm from the pylorus at 6 and 12 months postoperatively [14]. Unlike the previous, Fallahat et al. compared the gastric emptying in patients at 4 cm and 7 cm distance from pylorus 3 months postoperatively. The authors showed that resection at 4 cm from the pylorus were associated with delayed gastric emptying, and resection at 7 cm from the pylorus, with accelerated gastric emptying. The authors speculated that resection at 4 cm from the pylorus had as a consequence neural innervations of the antrum being abolished, contributing to slower emptying. These patients experienced nausea, vomiting, and poor appetite. On the other hand, the resection at 7 cm from the pylorus preserved the contractility of the antrum, leading to rapid gastric emptying due to the absence of redistribution process since the body and fundus were excised. These patients complained of dumping-like symptoms and had more frequent meals [42]. Further prospective randomized trials are needed to compare the motility changes and clinical symptoms in patients with the preservation or not of antrum.

There is scant information concerning the possible explanation of how these motility alterations may affect clinical symptoms or explain the underlying mechanisms of action. It seems that the technique is not standardized, and different sleeves are created. Thus, different residual gastric volumes are produced. Since now, no clear association was found between gastric volume and weight loss. Researchers suggest that the physiological changes and not the size of the sleeve are responsible as mechanisms of action. What is known is that LSG changes the profile of gut hormones. Sista et al. showed that the rapid gastric emptying was correlated with the increased production of GLP-1 in the distal bowel [16]. Burgerhart et al. associated postprandial symptoms with gastric emptying. No difference on gastric-emptying characteristics was found between patients with low or high postprandial symptoms [24]. Pomerri et al. found that patients presenting with a rapid gastroduodenal transit experienced better weight loss than patients presenting with a slow voiding rate [18]. It seems that little is known regarding the underlining mechanisms by which LSG controls appetite and food intake. Since the data are restricted to medium term, it would be interesting to see if the sleeve behaves differently in the long term and how weight regain is explained in some patients.

Bowel motility was the least studied. It seems that the food reaches the terminal ileum faster but arrives at the cecum later. Thus, the contact of the food with the area of terminal ileum is extended. Perhaps, this altered interaction of food with the gastrointestinal tract may be a key component to explain the neurohormonal changes via the stimulation of intestinal L cells producing incretions and understanding the underlining mechanisms which improve the metabolic profile of the patients.

The limitations of the review include the lack of standardization of the surgical technique, the different follow-up timings, the different measured outcomes, the small sample siz,e and the lack of available long-term data beyond four years.

Further pathophysiological studies are needed to investigate the exact correlation of the motility parameters with the clinical symptoms and gut peptide alterations and potential hormonal interactions between gastrointestinal tract and brain.

5. Conclusion

Laparoscopic sleeve gastrectomy has impacts on the gastrointestinal motility. The data remain debatable for esophageal motility. The stomach and small bowel motilities were accelerated, while the initiation of cecal filling and the ileocecal valve transit was delayed. Further pathophysiological studies are needed to investigate the exact correlation of the motility parameters with the clinical symptoms and gut peptide alterations.

Conflicts of Interest

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

References

  1. L. Angrisani, A. Santonicola, P. Iovino et al., “Bariatric surgery and endoluminal procedures: IFSO worldwide survey 2014,” Obesity Surgery, vol. 27, no. 9, pp. 2279–2289, 2017. View at Publisher · View at Google Scholar · View at Scopus
  2. M. M. Hutter, B. D. Schirmer, D. B. Jones et al., “First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass,” Annals of Surgery, vol. 254, no. 3, pp. 410–422, 2011. View at Publisher · View at Google Scholar · View at Scopus
  3. S. H. Chang, C. R. Stoll, J. Song, J. E. Varela, C. J. Eagon, and G. 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. View at Publisher · View at Google Scholar · View at Scopus
  4. R. T. Yehoshua, L. A. Eidelman, M. Stein et al., “Laparoscopic sleeve gastrectomy—volume and pressure assessment,” Obesity Surgery, vol. 18, no. 9, pp. 1083–1088, 2008. View at Publisher · View at Google Scholar · View at Scopus
  5. E. Sioka, G. Tzovaras, F. Tsiopoulos et al., “Esophageal motility after laparoscopic sleeve gastrectomy,” Clinical and Experimental Gastroenterology, vol. 10, pp. 187–194, 2017. View at Publisher · View at Google Scholar
  6. E. Kleidi, D. Theodorou, K. Albanopoulos et al., “The effect of laparoscopic sleeve gastrectomy on the antireflux mechanism: can it be minimized?” Surgical Endoscopy, vol. 27, no. 12, pp. 4625–4630, 2013. View at Publisher · View at Google Scholar · View at Scopus
  7. F. Mion, S. Tolone, A. Garros et al., “High-resolution impedance manometry after sleeve gastrectomy: increased intragastric pressure and reflux are frequent events,” Obesity Surgery, vol. 26, no. 10, pp. 2449–2456, 2016. View at Publisher · View at Google Scholar · View at Scopus
  8. F. Rebecchi, M. E. Allaix, C. Giaccone, E. Ugliono, G. Scozzari, and M. Morino, “Gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a physiopathologic evaluation,” Annals of Surgery, vol. 260, no. 5, pp. 909–915, 2014. View at Publisher · View at Google Scholar · View at Scopus
  9. G. Del Genio, S. Tolone, P. Limongelli et al., “Sleeve gastrectomy and development of “de novo” gastroesophageal reflux,” Obesity Surgery, vol. 24, no. 1, pp. 71–77, 2014. View at Publisher · View at Google Scholar · View at Scopus
  10. V. Gorodner, R. Buxhoeveden, G. Clemente, L. Solé, L. Caro, and A. Grigaites, “Does laparoscopic sleeve gastrectomy have any influence on gastroesophageal reflux disease? Preliminary results,” Surgical Endoscopy, vol. 29, no. 7, pp. 1760–1768, 2015. View at Publisher · View at Google Scholar · View at Scopus
  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. View at Publisher · View at Google Scholar · View at Scopus
  12. W. V. Petersen, T. Meile, M. A. Küper, M. Zdichavsky, A. Königsrainer, and J. H. Schneider, “Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity,” Obesity Surgery, vol. 22, no. 3, pp. 360–366, 2012. View at Publisher · View at Google Scholar · View at Scopus
  13. I. Braghetto, E. Lanzarini, O. Korn, H. Valladares, J. C. Molina, and A. Henriquez, “Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients,” Obesity Surgery, vol. 20, no. 3, pp. 357–362, 2010. View at Publisher · View at Google Scholar · View at Scopus
  14. M. Vives, A. Molina, M. Danús et al., “Analysis of gastric physiology after laparoscopic sleeve gastrectomy (LSG) with or without antral preservation in relation to metabolic response: a randomised study,” Obesity Surgery, vol. 27, no. 11, pp. 2836–2844, 2017. View at Publisher · View at Google Scholar · View at Scopus
  15. E. Mans, M. Serra-Prat, E. Palomera, X. Suñol, and P. Clavé, “Sleeve gastrectomy effects on hunger, satiation, and gastrointestinal hormone and motility responses after a liquid meal test,” The American Journal of Clinical Nutrition, vol. 102, no. 3, pp. 540–547, 2015. View at Publisher · View at Google Scholar · View at Scopus
  16. F. Sista, V. Abruzzese, M. Clementi, S. Carandina, M. Cecilia, and G. Amicucci, “The effect of sleeve gastrectomy on GLP-1 secretion and gastric emptying: a prospective study,” Surgery for Obesity and Related Diseases, vol. 13, no. 1, pp. 7–14, 2017. View at Publisher · View at Google Scholar · View at Scopus
  17. V. Pilone, S. Tramontano, R. Di Micco et al., “Gastric emptying after sleeve gastrectomy: statistical evidence of a controlled prospective study with gastric scintigraphy,” Minerva Chirurgica, vol. 68, no. 4, pp. 385–392, 2013. View at Google Scholar
  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. View at Publisher · View at Google Scholar · View at Scopus
  19. J. Melissas, S. Koukouraki, J. Askoxylakis et al., “Sleeve gastrectomy: a restrictive procedure?” Obesity Surgery, vol. 17, no. 1, pp. 57–62, 2007. View at Publisher · View at Google Scholar · View at Scopus
  20. J. Melissas, M. Daskalakis, S. Koukouraki et al., “Sleeve gastrectomy-a “food limiting” operation,” Obesity Surgery, vol. 18, no. 10, pp. 1251–1256, 2008. View at Publisher · View at Google Scholar · View at Scopus
  21. J. Melissas, A. Leventi, I. Klinaki et al., “Alterations of global gastrointestinal motility after sleeve gastrectomy: a prospective study,” Annals of Surgery, vol. 258, no. 6, pp. 976–982, 2013. View at Publisher · View at Google Scholar · View at Scopus
  22. D. Michalsky, P. Dvorak, J. Belacek, and M. Kasalicky, “Radical resection of the pyloric antrum and its effect on gastric emptying after sleeve gastrectomy,” Obesity Surgery, vol. 23, no. 4, pp. 567–573, 2013. View at Publisher · View at Google Scholar · View at Scopus
  23. T. Baumann, S. Kuesters, J. Grueneberger et al., “Time-resolved MRI after ingestion of liquids reveals motility changes after laparoscopic sleeve gastrectomy--preliminary results,” Obesity Surgery, vol. 21, no. 1, pp. 95–101, 2011. View at Publisher · View at Google Scholar · View at Scopus
  24. J. S. Burgerhart, P. W. van Rutte, M. A. Edelbroek et al., “Association between postprandial symptoms and gastric emptying after sleeve gastrectomy,” Obesity Surgery, vol. 25, no. 2, pp. 209–214, 2015. View at Publisher · View at Google Scholar · View at Scopus
  25. M. Parikh, J. Eisner, N. Hindman, E. Balthazar, and J. K. Saunders, “Tests of correlation between immediate postoperative gastroduodenal transit times and weight loss after laparoscopic sleeve gastrectomy,” Surgical Endoscopy, vol. 26, no. 12, pp. 3548–3551, 2012. View at Publisher · View at Google Scholar · View at Scopus
  26. B. Vigneshwaran, A. Wahal, S. Aggarwal et al., “Impact of sleeve gastrectomy on type 2 diabetes mellitus, gastric emptying time, glucagon-like peptide 1 (GLP-1), ghrelin and leptin in non-morbidly obese subjects with BMI 30-35.0 kg/m2: a prospective study,” Obesity Surgery, vol. 26, no. 12, pp. 2817–2823, 2016. View at Publisher · View at Google Scholar · View at Scopus
  27. S. Shah, P. Shah, J. Todkar, M. Gagner, S. Sonar, and S. Solav, “Prospective controlled study of effect of laparoscopic sleeve gastrectomy on small bowel transit time and gastric emptying half-time in morbidly obese patients with type 2 diabetes mellitus,” Surgery for Obesity and Related Diseases, vol. 6, no. 2, pp. 152–157, 2010. View at Publisher · View at Google Scholar · View at Scopus
  28. R. Berry, L. K. Cheng, P. Du et al., “Patterns of abnormal gastric pacemaking after sleeve gastrectomy defined by laparoscopic high-resolution electrical mapping,” Obesity Surgery, vol. 27, no. 8, pp. 1929–1937, 2017. View at Publisher · View at Google Scholar · View at Scopus
  29. A. A. Kandeel, M. D. Sarhan, T. Hegazy, M. M. Mahmoud, and M. H. Ali, “Comparative assessment of gastric emptying in obese patients before and after laparoscopic sleeve gastrectomy using radionuclide scintigraphy,” Nuclear Medicine Communications, vol. 36, no. 8, pp. 854–862, 2015. View at Publisher · View at Google Scholar · View at Scopus
  30. I. Braghetto, C. Davanzo, O. Korn et al., “Scintigraphic evaluation of gastric emptying in obese patients submitted to sleeve gastrectomy compared to normal subjects,” Obesity Surgery, vol. 19, no. 11, pp. 1515–1521, 2009. View at Publisher · View at Google Scholar · View at Scopus
  31. H. Bernstine, R. Tzioni-Yehoshua, D. Groshar et al., “Gastric emptying is not affected by sleeve gastrectomy--scintigraphic evaluation of gastric emptying after sleeve gastrectomy without removal of the gastric antrum,” Obesity Surgery, vol. 19, no. 3, pp. 293–298, 2009. View at Publisher · View at Google Scholar · View at Scopus
  32. V. N. Trung, H. Yamamoto, A. Furukawa et al., “Enhanced intestinal motility during oral glucose tolerance test after laparoscopic sleeve gastrectomy: preliminary results using cine magnetic resonance imaging,” PLoS One, vol. 8, no. 6, article e65739, 2013. View at Publisher · View at Google Scholar · View at Scopus
  33. M. Gagner, M. Deitel, T. L. Kalberer, A. L. Erickson, and R. D. Crosby, “The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009,” Surgery for Obesity and Related Diseases, vol. 5, no. 4, pp. 476–485, 2009. View at Publisher · View at Google Scholar · View at Scopus
  34. P. Prinz and A. Stengel, “Control of food intake by gastrointestinal peptides: mechanisms of action and possible modulation in the treatment of obesity,” Journal of Neurogastroenterology and Motility, vol. 23, no. 2, pp. 180–196, 2017. View at Publisher · View at Google Scholar · View at Scopus
  35. A. Inui, A. Asakawa, C. Y. Bowers et al., “Ghrelin, appetite, and gastric motility: the emerging role of the stomach as an endocrine organ,” The FASEB Journal, vol. 18, no. 3, pp. 439–456, 2004. View at Publisher · View at Google Scholar · View at Scopus
  36. P. Janssen, P. Vanden Berghe, S. Verschueren, A. Lehmann, I. Depoortere, and J. Tack, “Review article: the role of gastric motility in the control of food intake,” Alimentary Pharmacology & Therapeutics, vol. 33, no. 8, pp. 880–894, 2011. View at Publisher · View at Google Scholar · View at Scopus
  37. G. Tzovaras, D. Papamargaritis, E. Sioka et al., “Symptoms suggestive of dumping syndrome after provocation in patients after laparoscopic sleeve gastrectomy,” Obesity Surgery, vol. 22, no. 1, pp. 23–28, 2012. View at Publisher · View at Google Scholar · View at Scopus
  38. D. Papamargaritis, G. Koukoulis, E. Sioka et al., “Dumping symptoms and incidence of hypoglycaemia after provocation test at 6 and 12 months after laparoscopic sleeve gastrectomy,” Obesity Surgery, vol. 22, no. 10, pp. 1600–1606, 2012. View at Publisher · View at Google Scholar · View at Scopus
  39. E. Abdallah, A. El Nakeeb, T. Youssef et al., “Impact of extent of antral resection on surgical outcomes of sleeve gastrectomy for morbid obesity (a prospective randomized study),” Obesity Surgery, vol. 24, no. 10, pp. 1587–1594, 2014, Erratum in: Obes Surg. 2015 Oct;25(10):1987. Yousef, Tamer [Corrected to Youssef, Tamer]. View at Publisher · View at Google Scholar · View at Scopus
  40. F. Obeidat, H. Shanti, A. Mismar, N. Albsoul, and M. Al-Qudah, “The magnitude of antral resection in laparoscopic sleeve gastrectomy and its relationship to excess weight loss,” Obesity Surgery, vol. 25, no. 10, pp. 1928–1932, 2015. View at Publisher · View at Google Scholar · View at Scopus
  41. A. ElGeidie, M. ElHemaly, E. Hamdy, M. El Sorogy, M. AbdelGawad, and N. GadElHak, “The effect of residual gastric antrum size on the outcome of laparoscopic sleeve gastrectomy: a prospective randomized trial,” Surgery for Obesity and Related Diseases, vol. 11, no. 5, pp. 997–1003, 2015. View at Publisher · View at Google Scholar · View at Scopus
  42. B. Fallatah, A. AzizShehry, L. Abdelsamad, H. Zaid, S. Hussain, and S. Jaber, “Comparison study of gastric emptying after performing sleeve gastrectomy with two different techniques,” Journal of Surgery, vol. 1, no. 4, pp. 53–56, 2013. View at Google Scholar