Abstract
Background:
Laparoscopic sleeve gastrectomy (LSG) is a widely performed bariatric procedure, though the optimal distance from the pylorus for gastric transection remains debated. Differences in antral size may influence postoperative symptoms, complications, and weight outcomes, yet comparative evidence remains limited. This study compares LSG with antrectomy versus antrum preservation using real-world data from a high-volume center.
Methods:
A retrospective review of 157 patients who underwent primary LSG between 2019 and 2023 was conducted. Patients were categorized into antrum resection and antrum preservation groups based on standardized surgeon techniques. Outcomes included weight change, metabolic markers, complications, and patient-reported symptoms documented through structured EMR fields. Multivariable regression analyses were conducted after adjusting for age, sex, and surgeon.
Results:
Both groups achieved significant reductions in BMI and weight over 18 months, with no statistically significant differences at any follow-up time point (3-month P = 0.366, 6-month P = 0.932, 12-month P = 0.924, 18-month P = 0.445). Percentage total weight loss (%TWL) was comparable between groups at 1 year (34.3% vs. 30.6%, P = 0.088) and 18 months (40.6% vs. 31.8%, P = 0.076). Postoperative complications were significantly higher in the antrectomy group (9.6% vs. 1.4%, P = 0.036). Nausea was more frequently reported in the antrum-preserving group, while psychological symptoms, particularly feelings of failure, were more common following antrectomy.
Conclusion:
Both surgical techniques produced similar medium-term weight loss and metabolic outcomes. Antrum preservation demonstrated a more favorable safety profile and fewer negative psychological symptoms, whereas antrectomy was associated with increased complications. Larger prospective studies are required to determine long-term clinical and quality-of-life implications.
Keywords: Antral resection, antral preservation, bariatric surgery, laparoscopic sleeve gastrectomy, patient-reported outcomes, weight loss
INTRODUCTION
Bariatric surgery is an effective intervention for achieving long-term weight loss, improving comorbidities, and enhancing quality of life in patients with morbid obesity.[1] Among the various bariatric procedures, laparoscopic sleeve gastrectomy (LSG) has emerged as a widely practiced option. LSG involves reducing the stomach size by creating a tubular gastric sleeve, thereby limiting gastric expansion and inducing early satiety.[2] LSG has gained widespread adoption due to its advantages over other bariatric surgeries, including shorter operative times, lower complication rates, and favorable excess weight loss (EWL) outcomes ranging from 33% to 90%.[3,4,5] Despite these benefits, LSG is associated with drawbacks such as irreversibility and the risk of staple-line complications.[6]
As LSG continues to grow in popularity, several controversies remain, particularly regarding the optimal residual antrum size, the distance from the pylorus at which resection should begin, choice of staplers, and the application of reinforcement techniques. The physiological role of the antrum in regulating gastric emptying, intraluminal pressure, and peristaltic coordination suggests that variations in antral preservation may influence postoperative symptoms, gastric motility, and complication risk.[7,8]
In addition, while international literature has examined the effect of antrectomy versus antrum preservation, findings remain inconsistent, and few studies have explored these differences in Gulf or Saudi populations where obesity, diabetes, and metabolic syndrome are highly prevalent.
This study aims to evaluate patient-reported outcomes following LSG, with particular focus on the effects of residual antrum size.
PATIENTS AND METHODS
Study design and population
This retrospective cohort study included adults who underwent primary LSG between 2019 and 2023, at King Saud University Medical City. Patients with incomplete EMR data, revisional surgery, or missing weight/height documentation were excluded. A total of 157 patients met inclusion criteria, with 83 in the antrectomy and 74 in the antrum-preserving group.
Surgical technique
Two bariatric surgeons performed all procedures, each using a single, consistent technique throughout the study period. This minimized intra-surgeon variability but introduced surgeon-specific confounding, which was adjusted for in regression analyses.
Antrectomy technique
Gastric transection initiated 2 cm from pylorus
36-Fr bougie for calibration
Staple cartridges selected based on tissue thickness
Staple-line reinforcement performed when indicated
Routine intraoperative leak testing
Antrum preservation technique
Gastric transection initiated 5–6 cm from pylorus
The same 36-Fr bougie used for consistency
Identical reinforcement and leak-testing techniques as the antrectomy group
Data collection
Baseline variables included age, sex, comorbidities, ASA class, preoperative weight, height, BMI, and HbA1c.
Patient-reported symptoms
Patient-reported symptoms were assessed using structured questionnaires routinely administered at follow-up visits or by virtual follow-up, capturing nausea, vomiting, sleep quality, mood changes, and quality-of-life perceptions.
Variables were assessed using Shapiro–Wilk testing and compared by t-test or Mann–Whitney U test as appropriate. Categorical variables were assessed with Chi-square tests. BMI follow-ups were calculated and cleaned before analysis.
Multivariable logistic and linear regressions adjusted for age, sex, and surgeon were performed. Exact P values were computed for BMI, percentage total weight loss (%TWL), and at each time interval.
Institutional Review Board approval
This study was approved by the Institutional Review Board of King Saud University (IRB approval number: Project No. E-23-7845), granted on 11-6-2024.
RESULTS
A total of 157 patients met the inclusion criteria, comprising 83 in the antrectomy group and 74 in the antrum-preserving group. Baseline demographic and clinical characteristics were generally comparable, although the antrectomy group demonstrated a slightly higher preoperative BMI (47.4 vs. 44.3 kg/m²). Aside from BMI, both groups were similar in age, comorbidities, and ASA classification [Table 1].
Table 1.
Baseline demographic and clinical characteristics
| Variable | Antrectomy (n=83) | Antrum Preservation (n=74) |
|---|---|---|
| Age (years) | 36±13 | 37±13 |
| Female | 43 (51.8%) | 52 (70.3%) |
| Male | 40 (48.2%) | 22 (29.7%) |
| Previous surgery (Yes) | 31 (37.3%) | 35 (47.3%) |
| ASA I | 11 (13.3%) | 7 (9.5%) |
| ASA II | 36 (43.4%) | 53 (71.6%) |
| ASA III | 36 (43.4%) | 14 (18.9%) |
| Comorbidity (Yes) | 47 (56.6%) | 42 (56.8%) |
| Pre-op weight (kg) | 126.7±29.9 | 116.3±20.0 |
| Height (cm) | 163.6±10.3 | 161.4±10.3 |
| Pre-op BMI (kg/m²) | 47.37±10.3 | 44.29±6.8 |
| Pre-op HbA1c (%) | 6.5±1.8 | 6.1±1.5 |
Both surgical groups achieved substantial postoperative weight reduction over 18 months. At 3 months, the mean BMI was 38.60 ± 8.03 kg/m² in the antrectomy group and 37.11 ± 7.33 kg/m² in the antrum-preserving group (P = 0.366). At 6 months, the BMI values were 32.62 ± 6.39 kg/m² vs. 32.49 ± 5.34 kg/m² (P = 0.932). At 12 months, BMI remained similar between groups (30.67 ± 7.59 vs. 30.85 ± 5.45 kg/m²; P = 0.924), and this pattern continued at 18 months (28.90 ± 6.86 vs. 30.44 ± 5.58 kg/m²; P = 0.445). Although the antrectomy group exhibited slightly greater reductions across all time points, none of these differences reached statistical significance [Table 2; Figure 1].
Table 2.
Comparison of weight post-op between antrectomy and antrum preserving
| Outcome | Time point | Antrectomy (Mean±SD) | Antrum Preservation (Mean±SD) |
|---|---|---|---|
| BMI | 3 months | 38.60±8.03 | 37.11±7.33 |
| BMI | 6 months | 32.62±6.39 | 32.49±5.34 |
| BMI | 12 months | 30.67±7.59 | 30.85±5.45 |
| BMI | 18 months | 28.90±6.86 | 30.44±5.58 |
| %TWL | 1 year | 34.3% | 30.6% |
| %TWL | 18 months | 40.6% | 31.8% |
Figure 1.
Comparison of weight post-op between antrectomy and antrum preserving
Percentage total weight loss did not differ significantly between the two techniques. At 1 year, %TWL was 34.3% in the antrectomy group versus 30.6% in the antrum-preserving group (P = 0.088), and at 18 months, it was 40.6% vs. 31.8% (P = 0.076). These values showed a consistent numerical advantage for antrectomy but no statistical significance. Thus, despite slight numerical differences favoring antrectomy, weight-loss outcomes were ultimately similar [Table 2; Figure 1].
Metabolic outcomes followed the same pattern. Both groups showed meaningful reductions in HbA1c following surgery. Because of incomplete documentation of follow-up HbA1c values in the EMR, comparative analyses beyond baseline could not be reliably performed. Baseline HbA1c was similar between groups
In contrast to weight-loss metrics, postoperative complications demonstrated a significant difference. Complications occurred in 8 patients (9.6%) in the antrectomy group compared with only 1 patient (1.4%) in the antrum-preserving group (P = 0.036). Notably, all recorded leaks occurred exclusively in the antrectomy group, along with episodes of bleeding, dysphagia, pulmonary embolism, and one mortality (which is not related to the surgery). The antrum-preserving group experienced only one bleeding event. After adjustment for age, sex, and surgeon, antrum preservation remained associated with substantially lower odds of complications (adjusted OR ≈ 0.12; 95% CI 0.015–1.029), closely approaching statistical significance [Table 3; Figure 2].
Table 3.
Postoperative outcomes and Postoperative complications
| Outcome | Antrectomy n (%) | Antrum Preservation n (%) | P |
|---|---|---|---|
| Weight regain | 2 (2.4%) | 6 (8.1%) | 0.151 |
| Insufficient weight loss | 7 (8.5%) | 7 (9.5%) | 0.840 |
| ER visits <30 days | 11 (13.4%) | 7 (9.5%) | 0.440 |
| Readmission <30 days | 6 (7.2%) | 1 (1.4%) | 0.121 |
| ICU admission | 4 (4.8%) | 1 (1.4%) | 0.371 |
| Mortality (30-day) | 1 (1.2%) | 0 (0%) | 1.000 |
|
| |||
| Complication | Antrectomy n (%) | Antrum Preservation n (%) | P |
|
| |||
| Any complication | 8 (9.6%) | 1 (1.4%) | 0.036 |
| Staple-line leak | 2 (2.4%) | 0 (0%) | 0.498 |
| Bleeding | 3 (3.6%) | 1 (1.4%) | 0.622 |
| Dysphagia | 1 (1.2%) | 0 (0%) | 1.000 |
| Pulmonary embolism | 1 (1.2%) | 0 (0%) | 1.000 |
| Surgical-site infection (SSI) | 1 (1.2%) | 0 (0%) | 1.000 |
| Mortality (30-day) | 1 (1.2%) | 0 (0%) | 1.000 |
Figure 2.
Comparison of HbA1c post-op between antrectomy and antrum preserving
Table 3 summarizes postoperative outcomes for both surgical groups. Weight regain did not differ significantly between techniques, occurring in 2 patients (2.4%) in the antrectomy group and 6 patients (8.1%) in the antrum-preserving group (P = 0.151). Rates of insufficient weight loss were also similar, affecting 7 patients in each group (8.5% vs. 9.5%; P = 0.840).
Early healthcare utilization showed no significant differences: ER visits within 30 days occurred in 11 antrectomy patients (13.4%) and 7 antrum-preserving patients (9.5%) (P = 0.440), while readmissions within 30 days were recorded in 6 patients (7.2%) versus 1 patient (1.4%), respectively (P = 0.121).
ICU admissions were infrequent and comparable between groups (4.8% vs. 1.4%; P = 0.371). One 30-day mortality occurred in the antrectomy group, whereas no deaths were observed in the antrum-preserving group (P = 1.000).
The only outcome demonstrating a statistically significant difference was the overall complication rate, which was higher following antrectomy (9.6% vs. 1.4%; P = 0.036). [Figure 2].
Patient-reported outcomes showed no significant differences between the two groups in most domains. Nausea was more frequently reported in the antrum-preserving group and approached statistical significance (P= 0.054), while vomiting and overall quality of life did not differ significantly. Psychological symptoms, particularly feelings of failure or letting oneself or family down, were significantly more common in the antrectomy group (P = 0.022). Other psychological and sleep-related symptoms were comparable between groups [Table 4].
Table 4.
Patient-reported outcomes and logistic regression analysis
| Variable | Category | Antrectomy n (%) | Antrum Preservation n (%) | P | OR | 95% CI |
|---|---|---|---|---|---|---|
| Physical Activity post-op | Low | 14 (20.6%) | 6 (11.8%) | 0.323 | — | — |
| Moderate | 29 (42.6%) | 28 (54.9%) | — | — | ||
| High | 25 (36.8%) | 17 (33.3%) | — | — | ||
| Nausea Assessment | None | 35 (51.5%) | 21 (41.2%) | 0.175 | 2.369 | 0.987–5.685 |
| Mild | 22 (32.4%) | 14 (27.5%) | ||||
| Moderate | 9 (13.2%) | 15 (29.4%) | ||||
| Severe | 2 (2.9%) | 1 (2.0%) | ||||
| Vomiting Assessment | None | 29 (42.6%) | 27 (52.9%) | 0.099 | 1.264 | 0.491–3.254 |
| Mild | 28 (41.2%) | 14 (27.5%) | ||||
| Moderate | 11 (16.2%) | 7 (13.7%) | ||||
| Severe | 0 (0.0%) | 3 (5.9%) | ||||
| Quality of Life (overall) | — | — | — | — | 1.444 | 0.674–3.094 |
| Little interest or pleasure | Not at all | 52 (76.5%) | 40 (78.4%) | 0.115 | — | — |
| > half days | 6 (8.8%) | 0 (0.0%) | ||||
| Several days | 5 (7.4%) | 7 (13.7%) | ||||
| Nearly daily | 5 (7.4%) | 4 (7.8%) | ||||
| Feeling down/depressed | Not at all | 47 (69.1%) | 31 (60.8%) | 0.549 | — | — |
| > half days | 7 (10.3%) | 5 (9.8%) | ||||
| Several days | 6 (8.8%) | 9 (17.6%) | ||||
| Nearly daily | 8 (11.8%) | 6 (11.8%) | ||||
| Sleep disturbance | Not at all | 47 (69.1%) | 39 (76.5%) | 0.833 | — | — |
| > half days | 4 (5.9%) | 3 (5.9%) | ||||
| Several days | 8 (11.8%) | 4 (7.8%) | ||||
| Nearly daily | 9 (13.2%) | 5 (9.8%) | ||||
| Fatigue | Not at all | 26 (38.2%) | 22 (43.1%) | 0.224 | — | — |
| > half days | 7 (10.3%) | 11 (21.6%) | ||||
| Several days | 28 (41.2%) | 14 (27.5%) | ||||
| Nearly daily | 7 (10.3%) | 4 (7.8%) | ||||
| Appetite changes | Not at all | 28 (41.2%) | 20 (39.2%) | 0.311 | — | — |
| > half days | 15 (22.1%) | 6 (11.8%) | ||||
| Several days | 9 (13.2%) | 12 (23.5%) | ||||
| Nearly daily | 16 (23.5%) | 13 (25.5%) | ||||
| Feeling of failure | Not at all | 57 (83.8%) | 37 (72.5%) | 0.022 | — | — |
| > half days | 5 (7.4%) | 2 (3.9%) | ||||
| Several days | 4 (5.9%) | 12 (23.5%) | ||||
| Nearly daily | 2 (2.9%) | 0 (0.0%) | ||||
| Concentration difficulty | Not at all | 43 (63.2%) | 36 (70.6%) | 0.688 | — | — |
| Psychomotor changes | Not at all | 49 (72.1%) | 43 (84.3%) | 0.398 | — | — |
| Self-harm thoughts | Not at all | 63 (92.6%) | 48 (94.1%) | 0.831 | — | — |
DISCUSSION
The standardization of surgical techniques is crucial. Establishing evidence-based and consistent surgical steps reduces variability and ensures reliable results that contribute to evaluating and improving outcomes. LSG is an example of a surgical procedure that varies significantly among surgeons. These variations range from patient selection, preoperative preparation, port placement, intraoperative techniques (e.g., segmental antrectomy vs. antral preservation), stapler choices, and reinforcement methods, to postoperative plans and follow-up protocols.[9]
In this study, we examined two intraoperative approaches: resecting part of the antrum versus preserving it. Segmental antral resection is defined as starting the division 2 cm from the pylorus, while antral preservation begins at 5–6 cm from the pylorus. The exact starting point for antral resection varies in the literature, as does the bougie size used.[9,10] Preserving a larger portion of the antrum is theorized to maintain more of the gastric pump function, support coordinated gastric emptying, and reduce intraluminal pressure along the proximal staple line. This may, in turn, lower the risk of leaks or facilitate earlier fistula healing.[9,10,11,12,13,14,15,16,17,18] On the other hand, some believe antral resection offers better weight loss, particularly in super obese patients.[11]
In our study, we evaluated BMI and mean weight reduction in both the antral-preserving and antrectomy groups at 3, 6, 12, and 18 months. We found no statistically significant differences in BMI or weight reduction between the two groups at any time point. These findings differ from several previous studies. Eskandaros et al. reported significant BMI and weight reductions at 3, 6, and 12 months,[10] while Omarov et al. found a significant BMI reduction only at 3 months postoperatively, and Obeidat et al. reported significant differences at 24 months as well.[12,13] Our results align instead with other studies suggesting that antral size does not substantially influence medium-term weight-loss trajectories when similar bougie sizes and postoperative protocols are used.
Both our groups had similar rates of weight regain and insufficient weight loss. Avlanmis et al.[14] reported better weight loss and maintenance of %EWL in the antrectomy group. However, this contrasts with Garay et al.,[15] who found no significant difference in %EWL between the groups. Abdallah et al.[9] reported no increase in complication rates with antral resection, while in our study, the antrectomy group had a significantly higher complication rate compared to the antral-preserving group (9.6% vs. 1.4%, P = 0.036). This is noteworthy, especially because all staple-line leaks occurred exclusively in the antrectomy cohort, a pattern that may reflect increased distal gastric pressure and mechanical tension on the staple line when less antrum is preserved.
We also evaluated nausea, vomiting, and quality of life (QOL) using structured symptom questionnaires routinely administered in our center. Patients who underwent antral-preserving surgery had higher odds (OR 2.369) of experiencing nausea compared to those who had antrectomy, but the difference was not statistically significant (P = 0.054). This trend may be explained by delayed gastric emptying associated with a larger preserved antrum, which has been described in physiological studies and may contribute to transient postoperative nausea.[9,10,18] No significant differences were found between the two groups in terms of vomiting or QOL. These findings align with ElGeidie et al., who reported similar results for nausea, vomiting, and QOL between the groups, although they concluded that QOL generally improved from baseline in both groups.[16]
Similarly, Kirkil et al.[17] explored this issue using a questionnaire among 562 participants; they concluded that QOL improved for most respondents. In contrast, our study found no significant QOL difference between the two groups. However, patients who underwent antrectomy reported significantly more feelings of failure or of letting themselves or their families down compared to those who underwent antral preservation (P = 0.022). This psychological effect may be related to a more difficult postoperative recovery course or the higher complication burden observed in the antrectomy cohort. Other psychological symptoms such as depression, sleep disturbances and suicidal thoughts were similar between groups.
Furthermore, several meta-analyses of randomized controlled trials have compared these two techniques. Diab et al.[18] found that a longer distance from the pylorus (around 6 cm) was associated with prolonged vomiting and gastroesophageal reflux disease (GERD), supporting the findings observed in our population. McGlone et al. defined antral resection as starting 2–3 cm from the pylorus and antral preservation as starting more than 5 cm from the pylorus, where their results showed better weight loss with antral resection, with no significant increase in complication rate.[19] These conflicting findings in the literature underscore the complexity of determining a universally optimal antral size as both physiologic and clinical outcomes vary across populations, surgical techniques and postoperative protocols.
This study contributes to the limited regional evidence available from Gulf populations, which have disproportionately high rates of obesity, diabetes, and metabolic syndrome. The finding that antrum preservation maintains equivalent weight loss while reducing complication risk may support adopting a more conservative antral preservation approach in Saudi Arabia and similar settings.
One major limitation of our study is its retrospective chart review design, which may introduce bias in documentation. Additionally, the limited availability of follow-up HbA1c and symptom data reflects real-world EMR completeness. A larger sample size would be beneficial to better distinguish differences between the two techniques. Finally, the medium-term follow-up period (18 months) does not allow conclusions regarding GERD development or long-term weight regain, both of which warrant further prospective study.
In summary, in this retrospective cohort of 157 patients, antrectomy and antrum-preserving LSG produced comparable medium-term weight-loss and metabolic outcomes, with no significant differences in BMI or percentage total weight loss (%TWL) up to 18 months. However, antrectomy was associated with a substantially higher complication rate, including all recorded leaks, whereas antrum preservation demonstrated a safer profile without compromising effectiveness. Symptom patterns differed between groups, with increased nausea in the preservation group but a higher burden of psychological distress, particularly feelings of failure, among antrectomy patients.
Together, these findings support consideration of antrum preservation (5–6 cm from the pylorus) as a safe and effective approach in routine LSG, particularly in Gulf populations with high obesity and comorbidity burdens. Prospective, multicenter studies with validated patient-reported outcome measures and long-term follow-up are needed to confirm these observations and further evaluate GERD, weight-regain trajectories, and quality-of-life outcomes.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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