OBES SURG

DOI 10.1007/s11695-016-2274-1

ORIGINAL CONTRIBUTIONS

Changes in Gastric Volume and Their Implications for Weight

Loss after Laparoscopic Sleeve Gastrectomy
Manuel Ferrer-Márquez 1 & Juan José García-Díaz 2 & Almudena Moreno-Serrano 1 &
José Miguel García-Díez 3 & Manuel Ferrer-Ayza 1 & Raquel Alarcón-Rodríguez 4 &
Enrique G. Artero 5 & Alberto Soriano-Maldonado 6

# Springer Science+Business Media New York 2016

Abstract 1 (68.39 ± 25.89 cm3) and 12 postoperative months (122.58 ±

Background Laparoscopic sleeve gastrectomy (LSG) is a rel-
atively new surgical technique for the treatment of morbid
obesity. It is unclear whether the volume of the gastric remnant
can expand after surgery as a result of intraluminal pressure
maintained over time. If this were the case, the increased vol-
ume could affect weight loss and the improvement in comor-
bidities. This study aims to assess the evolution of residual
gastric volume (RGV) during the first year after LSG and its
relationship with weight loss.
Material and Methods We conducted a prospective study of
112 patients who underwent LSG from February 2009 to
December 2013. In order to measure the RGV after sur-
gery, all patients were evaluated radiologically by an
esophagogastroduodenal (EGD) transit at 1 and 12 postoper-
ative months.
Results All patients showed a significant reduction in BMI
compared with the preoperative measurement (33.48 ± 5.78
vs. 50.54 ± 6.69 kg/m2; p < 0.001). Increased RGV was ob-
served when comparing the results obtained by EGD transit at
* Manuel Ferrer-Márquez
manuferrer78@hotmail.com
1
Bariatric Surgery Department, Complejo Hospitalario Torrecárdenas,
Almería, Spain
2
Torrecárdenas Hospital, Almería, Spain
3
Department of Radiology, Torrecárdenas Hospital, Almería, Spain
4
Medical area, University of Almería, Almería, Spain
5
Department of Education, Area of Physical Education and Sport,
University of Almería, Almería, Spain
6
Department of Physical Education and Sport, Faculty of Sport
Sciences, University of Granada, Granada, Spain
38.76 cm3; p < 0.001). There was no association between in-
crease in gastric volume and weight loss at 1-year follow-up
(r = 0.01; p = 0.910).
Conclusions The volume of the gastric remnant increased sig-
nificantly during the first year after LSG. However, this in-
crease was not associated with weight loss. Further prospec-
tive research with longer follow-up periods is needed to con-
firm or contrast the present results.
Keywords Laparoscopic sleeve gastrectomy . Obesity .
Esophagogastroduodenaltransit . Gastric volume . Weight loss
Introduction
Laparoscopic sleeve gastrectomy (LSG) is a surgical tech-
nique that has gained popularity worldwide in the treatment
of morbid obesity. Its mechanism of action is twofold: on the
one hand, LSG is a predominantly restrictive procedure, cre-
ating a feeling of early satiety in the patient; on the other hand,
when resecting the gastric fundus, the levels of ghrelin (an
appetite-stimulating hormone [1, 2]) decrease.
This technique is considered a supplementary restrictive part
of other methods known as mixed techniques: we refer to the
duodenal switch, in which a biliopancreatic diversion is also
performed. In 1999, Gagner and Patterson [3] conducted the
first LSG as part of a duodenal switch procedure at Mount Sinai
Hospital in New York. Since then, many surgical teams have
successfully adopted this technique. However, its indications
remain unclear. LSG is supported by some institutions [4] as
a first step in high-risk patients and in those with a high body
mass index (BMI), with the intention that a second, definitive
procedure should be performed after achieving a satisfactory
weight loss in order to reduce surgical risk. On the other hand,
 OBES SURG

other surgical teams consider it an alternative to gastric bypass

or biliopancreatic diversion with duodenal switch [5, 6].
The mechanism of action of the sleeve gastrectomy is be-
lieved to involve a combination of gastric restriction, hormonal
effects, and changes in gastric motility and eating habits [2].
The reduction of gastric volume, which inhibits food intake, is
considered one of the main mechanisms of action of LSG.
Therefore, the residual gastric volume (RGV) is essential to
achieve optimal weight loss results [7–9]. The RGV after sur-
gery may be influenced by several factors, including the size of
the bougie used in the procedure, the distance of the first sec-
tion from the pylorus, the distance between the bougie and the
suture line, or the use of reinforcement material in the gastric Fig. 1 Invagination using a running suture
section [10–17]. Given these factors, it would be important to
monitor postsurgery RGVover time and relate it to weight loss. extracted, leaving an aspiration drainage. Neither nasogastric
Since this is a technique that transforms the stomach into a nor bladder tubes were used. During the postoperative period,
cylinder, which continues from esophagus to duodenum, it is the patient was mobilized the night of surgery. A methylene
unclear whether it can expand as a result of intraluminal pres- blue test was performed at 24 h, and if the results were nega-
sure maintained over time. In that event, this increase in vol- tive, the patient received a liquid diet to assess their tolerance.
ume could affect weight loss and related comorbidities. If no incidents were registered, the patient was discharged 72 h
This study aims to assess the evolution of RGV during the after surgery.
first year after LSG and its relationship with weight loss.

Follow-up
Material and Methods
All patients received a semi-liquid diet during the first four
We conducted a prospective observational study of patients postoperative weeks and were evaluated at outpatient clinics
who underwent consecutive surgery between February 2009 at 1, 3, 6, and 12 months after surgery. A regular follow-up
and December 2013. All of the patients were operated on by was also maintained by contact with the nutrition team.
the bariatric surgery team of Torrecárdenas Hospital in
Almería, Spain. This surgical team was composed of three
surgeons and a multidisciplinary team of endocrinologists, nu-
tritionists, and psychologists. Surgery candidates were patients
with BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with comorbidities.
Once surgery was indicated, these patients were evaluated by
the bariatric committee in order to be registered on the surgical
waiting list. Among the variables considered were age, sex,
weight, BMI, comorbidities, complications, length of stay, per-
cent excess BMI loss (%EBMIL), and volume of the gastric
remnant.

Surgical Technique

The procedure began with the insertion of a supraumbilical

optical trocar and the placement of four secondary trocars.
The greater curvature of the stomach was resected using the
LigaSure system, starting 4 cm from the pylorus and extending
up to the angle of His. All adhesions to the posterior gastric
wall were released. A 34-Fr Faucher tube was inserted prior to
the gastric section. The section was performed with an
endocutter and subsequently reinforced with a 2–0 resorbable
monofilament invaginating suture (Fig. 1). A methylene blue Fig. 2 Volume measurements in an EGD transit. H = height;
leak test was performed, and the surgical specimen was D = diameter; R = radius
OBES SURG

Gastric Volume Statistical Analysis

In order to measure the RGV after surgery, all patients were
evaluated radiologically by an esophagogastroduodenal
(EGD) transit at 1 and 12 postoperative months. Considering
the residual stomach as a cylinder, the volume was calculated
according to the following formula: V = πr2h (in cm3), where
h = height and r = radius (Fig. 2).
The patient was prepared with a low-residue diet from
48 h and fasting from 8 to 12 h before the test. The
diagnostic test was performed by the same radiologist
throughout the study. An oral, diluted water suspension
of barium sulfate was administered to the patient, except
in cases of suspected perforation, for which Gastrografín®
was used instead. The examination table was placed at
different angles to obtain the right images and record the
necessary measurements of the gastric remnant. Thus, the
height (h) of the cylinder was measured from the cardia to
the pylorus. The diameter (D) was measured considering
its three maximum values in the upper, middle, and lower
thirds of the remnant. Finally, the average of these mea-
surements was obtained.
Weight Loss
Weight loss in the present study was assessed through the
%EBMIL, which was calculated with the following formula
[10]:
%EBMIL ¼ ðpreoperative BMI–1−year follow−up BMIÞ
. sults regarding weight loss (92.24 kg) and BMI reduction
ðpreoperative BMI−25Þ  100
Descriptive statistics are presented as means and standard devia-
tions unless otherwise indicated. The comparison of RGV from
baseline to 1-year follow-up was analyzed with paired samples t
test with RGV as dependent variable and time as independent
variable. The association of RGV with weight loss was examined
with the Pearson’s correlation coefficient. All statistical analyses
were performed with SPSS software (version 22.0 for Windows),
and the statistical significance was set at p < 0.05.
Results
A total of 112 patients underwent surgery between February
2009 and December 2013. All patients attended follow-up ex-
aminations during the first postoperative year, with the excep-
tion of two patients that did not agree to undergo the EGD
transit. For this reason, the sample for volume measurements
12 months after surgery was 110 patients. Preoperative charac-
teristics are shown in Table 1. Eighty percent of the patient
population were women, with an average age of 41 (20–60)
years, a weight of 138.68 (78–193) kg, and a BMI of 50.54
(35.13–66.22) kg/m2. The patients underwent LSG with a mean
operative time of 68.48 (30–220) minutes. An intraoperative
complication was reported: stapling of the nasogastric tube.
After being introduced during surgery, the tube was accidental-
ly stapled when performing the gastric section. This required
opening the gastric tube, removing the stapled tube, and sutur-
ing it back. The average hospital stay was 3.3 (3–21) days.
At 12 months after surgery, all patients reported good re-
when compared with the preoperative measurement (33.48

Table 1 Characteristics of the

study participants at baseline and Parameters Preoperative 12 months after surgery
1-year follow-up
Number of patients 112
Age (years) 41.28 (20–60)
Weight (kg) 138.68 (78–193) 92.24 (58–145)
BMI (kg/m2) 50.54 33.48
Comorbidities
• Hypertension 56.6 % 17 %
• DM 31.2 % 8%
• OSAS 56.2 % 0.9 %
• Dyslipemia 24.1 % 2.7 %
Lenght of hospital stay (days) 3.32 (3–21)
%EBMIL 67.54
Complications
• Fistula 3
• Bleeding 1
• Stenosis 1

Table 2 Paired-samples t test comparing gastric volume at 1 month and 1 year following laparoscopic sleeve gastrectomy
Number Minimum
Volume at 1 month 112 18.84
Volume at 12 months 110 25.13
± 5.78 vs. 50.54 ± 6.69 kg/m2, respectively; p < 0.001). The
%EBMIL was 67.54 % at 12 months after LSG.
The postoperative complications included three fistulas
(4.1 %), a complete stenosis (1.4 %), and bleeding (1.4 %).
The three fistulas were diagnosed after discharge, when the
patients were readmitted for fever and dyspnea. One of the
fistulas resolved with conservative treatment and stenting,
while the other two required surgical treatment. The stenosis
required conversion of the surgery to gastric bypass. Bleeding
was resolved by surgical revision and small-vessel hemosta-
sis. All adverse events occurred during the first 35 procedures
of the learning curve. The 112 patients completed the 12-
month follow-up, and no one died during this period.
Regarding the RGV determined by gastroduodenal study,
an increase was observed when comparing the results at 1
(68.39 ± 25.89 cm3) and 12 months after surgery (122.58 ±
38.76 cm3; p < 0.001) (Table 2). There was no correlation
between increased gastric volume and %EBMIL (r = 0.01;
p = 0.910; Fig. 3).
Discussion
The main findings of the present study, conducted in 112
individuals undergoing LSG, indicate that RGV increases sig-
nificantly following surgery. However, increases in RGV
seem not to affect weight loss.
Fig. 3 Graphical representation
of the correlation between
increased gastric volume and
%EBMIL
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Maximum Mean SD p
196.34 68.39 25.89 <0.001
274.88 122.58 38.76
The reduction of gastric volume, which inhibits food in-
take, is considered one of the main mechanisms of action of
LSG. Thus, the RGV is essential to achieve optimal weight
loss results [7–9]. Factors such as the size of the bougie used
in the procedure, the distance of the first section from the
pylorus, the distance between the bougie and the suture line,
or the use of reinforcement material in the gastric section
[11–18] may influence the RGV and have an impact on
long-term weight loss results.
It is unclear whether the RGV after surgery may increase as
a result of increased intraluminal pressure over time. If this
were the case, the results could be subsequently worsened or
patients would begin to gain weight.
In clinical practice, radiological studies after LSG are usu-
ally performed when there is suspicion of complications or
inadequate weight loss. However, the correlation between
the gastric volume during follow-up and weight loss [8] re-
mains ambiguous.
In 2014, Vidal et al. [9] assessed the gastric volume of 45
patients immediately after LSG and 1 year later and analyzed
its relationship with weight loss. This was a prospective study
in which the volume of the gastric pouch was assessed by
considering the image as a complex geometrical shape with
two components: a cylinder (gastric body) and a truncated
cone (antrum). The volume estimation was performed using
an EGD transit with Gastrografin®, by measuring the maxi-
mum height and radius of the cylinder, both in anteroposterior
OBES SURG
or 90° lateral projections. Although no correlation was ob-
served at 3, 6, and 12 months between increased gastric res-
ervoir volume and percentage of excess weight loss (%EWL)
(p = 0.060, p = 0.130, and p = 0.082, respectively), correlation
was statistically significant at 18 months (p = 0.006).
Braghetto et al. [19] reported a prospective study compar-
ing, in a limited sample of only 15 patients, the gastric capac-
ity evaluated with computerized axial tomography (CT) and
barium sulfate at 3 days and 24 months after surgery. The
postoperative volume was 108 ± 25 and 116.2 ± 78.2 ml, mea-
sured with barium sulfate and CT, respectively. At 2 years, the
volume had increased to 250 ± 85 and 254 ± 56.8 ml.
However, weight loss was not affected and patients remained
stable with a BMI close to 25 and no weight regain.
In line with the aforementioned studies, we observed a sig-
nificant increase in volume from 1 to 12 months after surgery
(69.46 and 117.58 cm3, respectively). Importantly, the increase
in RVG had no association whatsoever with weight loss. Our
surgical team used an EGD transit to measure gastric volume,
given its similarity with a cylinder shape. Thus, we obtained
radiological images, which were calibrated and measured to
subsequently calculate the RGV by applying the formula
V = πr2h.
Barbiero et al. [8] recently published a study of 49 patients
undergoing LSG. The RGVof these patients was measured by
comparing those with gastric pouch (n = 36) and those without
(n = 13). The Bgastric pouch^ was defined as the gastric rem-
nant or saccular dilatation of the cranial gastric portion of the
intestine. The gastric volume was calculated by an EGD tran-
sit with water-diluted barium, measuring the anteroposterior,
latero-lateral, and vertical diameters. They concluded that
there was no correlation between the volume of the gastric
pouch after LSG in symptomatic patients or those with unsat-
isfactory weight loss.
Deguines et al. [7] prospectively studied the RGV at over
24 months after LSG by using a gastric computed tomography
volumetry (GCTV) and comparing the parameters obtained
with the results of surgery. Revisional surgery was offered when
the RGV exceeded 250 cc. They included 66 patients that dif-
fered significantly when comparing Bsuccess^ (%EWL >50 %)
and Bfailure^ (%EWL ≤50 %) groups (309 vs. 225 cc, respec-
tively; p = 0.0003). They concluded that a high RGV at
34 months after surgery is a risk factor for failure in weight loss.
Nevertheless, it remains unclear why some patients present
an increased RGV. Possible explanations include technical er-
rors during surgery and a difference in stomach inflation from
patient to patient due to variations in the properties of each
patient’s gastric walls. Another possibility is that some patients
may not follow dietary guidelines after surgery, thus causing an
increased intraluminal pressure maintained over time [7].
The fact that increase in gastric volume was not associated
with reduced weight loss supports the role of other factors
positively influencing weight loss following LSG. The
reduction of plasmatic ghrelin levels with LSG contributes
to saciety, lower appetite stimulation, and consequently,
weight loss [20]. The resection of the pyloric antrum might
also be associated with an increase in gastric emptying with-
out increasing gastro-esophageal reflux or the risk of leaks
[21]. It has also been suggested that accelerated gastric emp-
tying associated with enhanced postprandial cholecystokinin
and glucagon-like peptide-1 concentrations could contribute
to improved weight loss and glucose metabolism [22].
Several articles regarding the volume of the resected stomach
(VRS) and its relationship with weight loss have been recently
published. Obeidat et al. [23] studied 90 patients undergoing
LSG, measuring the VRS by injecting saline solution until leak-
age was observed at the suture line. A significant correlation was
found between VRS and %EWL a year after surgery. Patients
with a VRS greater than 1100 ml showed a higher %EWL at
12 months than those with a VRS lower than 1100 ml.
Similarly, Singh et al. [24] studied 100 patients that were
divided into three groups according to the following VRS:
700–1200 ml (group A), 1200–1700 ml (group B), and
>1700 ml (group C). They concluded that mean %EWL after
LSG was not significantly different among the three groups of
patients, and the VRS was significantly greater in patients
with a higher preoperative BMI.
Bekheit et al. [25] conducted a more recent study, in which
they included 287 patients undergoing surgery, and measured
the VRS by filling it with water to full capacity. The sample
was divided into the following two groups: group 1 (preoper-
ative BMI ≤50 kg/m2) and group 2 (preoperative BMI >50 kg/
m2). Group 2 showed a greater VRS than group 1 did (1663
vs. 1440 ml; p < 0.001). In a multiple regression analysis, the
preoperative BMI was a predictor of %EWL at 6 and
12 months, while VRS was not.
The best imaging techniques used to evaluate the results after
LSG remain difficult to choose. The EGD transit has been the
most widely used technique to determine the presence of fistula,
stenosis, and gastroesophageal reflux and, as proposed in previ-
ous studies, to evaluate RGV. A low radiation exposure is
among its advantages compared with other techniques, although
its precision is limited as it does not measure tridimensionally.
The use of CT is usually limited to the diagnosis of internal
hernias and early postoperative complications [26–30]. A recent
study showed that CT may provide the same information as the
EGD transit in the immediate postoperative period, except that
CT shows more incidental findings [31]. Some recent studies
suggest the usefulness of multidetector CT with multiplanar re-
construction and three-dimensional imaging with or without
contrast agents. Its use to evaluate adjustable gastric banding
and possible complications is reported elsewhere [32]. A team
in Lyon (Blanchet et al. [33]) published for the first time the
results of a 3D gastric computed tomography with air and ar-
gued that it is a helpful decision-making technique in patients
with failure or complications after bariatric surgery. It seems

particularly useful in visualizing gastric capacity. The main con-
cern regarding the use of these techniques is the risk associated
with radiation exposure, the use of sophisticated technological
equipment, a larger study time, and especially, the excessive
costs involved.
This study has limitations that must be underlined. We
considered the gastric tube as a cylinder to calculate its vol-
ume, although the stomach does not always have a perfect
cylinder shape, which might have led to measurement bias.
However, previous studies have shown that this technique
allows calculating gastric volume with reasonable accuracy
[33, 34]. In addition, the short follow-up period (1 year) pre-
cludes identifying larger gastric volume increases and poten-
tial associations with weight loss with longer follow-up.
Therefore, further research is warranted.
Conclusions
The volume of the gastric remnant increased significantly dur-
ing the first year after LSG. However, this increment seems
not to affect weight loss. Further prospective studies with lon-
ger follow-up are needed to determine whether the apparent
increase in gastric volume following LSG (if it indeed takes
place) does not hinder weight loss maintenance or, on the
contrary, slows or even reverses it.
Acknowledgments A S-M was funded by the Spanish Ministry of
Education, Culture, and Sport (grant number FPU12/00963). E.G.A.
was funded by the Spanish Ministry of Economy and Competitiveness
(MINECO) (RYC-2014-16390).
Compliance with ethical standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethical Approval All procedures performed in studies involving hu-
man participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable ethical
standards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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