Comment on antrum resection versus antrum preservation in laparoscopic sleeve gastrectomy: Unaddressed issues

Abstract

Dear Editor,

We read with great interest the retrospective cohort study by Aljomah et al.[1] comparing patient-reported outcomes after antrum resection versus antrum preservation in laparoscopic sleeve gastrectomy (LSG). The authors are to be commended for addressing a clinically relevant and ongoing surgical controversy using real-world data from a high-volume center in Saudi Arabia, a region where obesity and metabolic syndrome are highly prevalent.[2] The finding that antrum preservation achieved comparable medium-term weight loss while demonstrating a significantly lower complication rate (1.4% vs. 9.6%, P = 0.036) is particularly noteworthy. However, several methodological considerations warrant further discussion.

First, the retrospective design and reliance on electronic medical record (EMR) data introduce inherent limitations that may affect the validity of the patient-reported outcome comparisons. The authors acknowledge incomplete documentation of follow-up HbA1c values, which precluded reliable metabolic comparisons beyond baseline. This raises the question of whether other patient-reported symptoms—particularly psychological outcomes such as “feelings of failure” that were significantly more common in the antrectomy group (P = 0.022)—might also be subject to documentation bias. Were structured questionnaires administered uniformly to both groups, or were symptoms recorded opportunistically during clinical encounters? Clarifying the consistency of data collection would strengthen the interpretation of these psychological findings.

Second, the authors adjusted for surgeon in their multivariable regression analyses to minimize surgeon-specific confounding. However, the study included only two surgeons, each using a single consistent technique. This raises the possibility that the observed differences in complications and psychological outcomes may partly reflect surgeon-level factors—such as experience, technique proficiency, or perioperative management—rather than the antral resection technique itself. Although statistical adjustment was performed, the small number of surgeons limits the ability to fully disentangle technique from surgeon effects. Future multicenter studies with larger numbers of surgeons would help address this concern.

Third, the authors report that all recorded staple-line leaks occurred exclusively in the antrectomy group, a pattern they attribute to increased distal gastric pressure and mechanical tension. While this physiological explanation is plausible, it would be valuable to know whether the two groups differed in other intraoperative variables that might influence leak risk—such as stapler cartridge selection, tissue thickness, or the use of staple-line reinforcement. The authors note that reinforcement was performed “when indicated,” but details on the frequency and criteria for reinforcement in each group are not provided. This information would help contextualize the notable difference in complication rates.

Fourth, the trend toward higher nausea rates in the antrum-preserving group (OR 2.369, P = 0.054) is attributed to delayed gastric emptying associated with a larger preserved antrum. However, the authors did not perform objective gastric emptying studies to confirm this mechanism. Given that the bougie size was identical between groups (36-Fr), could other factors—such as differences in vagal nerve preservation or postoperative dietary progression—also contribute to this symptom pattern? Prospective studies with objective motility assessments would help clarify the underlying physiology. Previous randomized studies have reported variable effects of antral size on gastric emptying and nausea,[3,4] and meta-analyses have also highlighted the association between antral preservation and reflux symptoms,[5,6] further underscoring the need for standardized physiologic evaluations.

Finally, the authors emphasize the importance of these findings for Gulf populations with high obesity and comorbidity burdens.[7] We agree that antrum preservation appears to offer a favorable balance of safety and efficacy in this context. However, the medium-term follow-up of 18 months does not permit conclusions about long-term outcomes, particularly gastroesophageal reflux disease (GERD) and weight regain trajectories that the authors themselves acknowledge as important unanswered questions. Long-term prospective studies with validated patient-reported outcome measures will be essential to confirm whether the observed benefits of antrum preservation are sustained over time.

Despite these limitations, Aljomah et al.[1] have provided valuable evidence supporting a more conservative antral preservation approach in LSG. Their work contributes important regional data to a global surgical debate and highlights the need for standardized, prospective investigations to optimize surgical technique and improve patient outcomes.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.