LSG is the most performed procedure for the management of morbidly obese patients because it has a low rate of complications and allows rapid return to social life and work. Nevertheless, the LSG methodology is not completely developed, and there are also several contentious issues. One such issue is the start of the gastric resection and the resection distance from the pyloric antrum; some prefer antral resection with stapling starting 2 cm from the pylorus to provide a more restrictive effect of the sleeve and achieve greater weight loss , whereas others start 6 cm from the pylorus, thereby maintaining the gastric antrum with the intention of maintaining its contractile power and thereby enhancing gastric emptying .
Baumann et al.  developed a new research tool to test gastric movement in patients with antrum-preserving LSG. Magnetic resonance imaging was performed in five patients 6 days before and 6 months after LSG. It was shown that the accelerated antral gastric emptying was directly related to the conservation of the antrum, because the sleeve itself showed no propulsive peristalsis. This is inconsistent with other studies that have shown enhanced gastric emptying after complete antral resection . In contrast, Bernstine et al.  did not notice any major differences in gastric emptying in a prospective study of 21 patients who underwent an antrum-conserving procedure and had a scintigraphy test before and 3 months after LSG.
Antral conservation advocates consider that preservation of the antrum may minimize distal gastric obstruction and the chance of proximal leakage at the angle of His ; on the other hand, antral resection supporters say that stapling within 2 cm of the pylorus is more restrictive and may lead to greater weight loss .
With regard to weight loss results based on the length of the antrum, two new reports showed improved weight loss results for a division near the pylorus. In a study of 110 patients, Obeidat et al.  found that, by 2 years postoperatively, complete resection of the antrum safely enhanced the restrictive results with slightly improved weight loss compared to antrum conservation. Similarly, Abdallah et al. recorded slightly improved weight loss by increasing the volume of the antrum resected. In contrast, our research showed no substantial differences in weight loss outcomes (%EWL) between the two groups at 1-year follow-up (69% ± 6% in the 2 cm group and 70% ± 5% in the 6 cm group, p = 0.697). The study by Garay et al.  showed similar results; no significant difference in %EWL at 1 year after LSG was seen between patients who had antrum resection 2 cm from the pylorus and those who had resection 5 cm from the pylorus (54.9% ± 15% vs. 57.7% ± 23%, respectively; p = 0.74).
In our work, although the two study groups showed resolution of comorbidities throughout the postoperative follow-up period, there were no statistically significant differences between the two groups (p > 0.05). Lakdawala et al.  reported 98% DM resolution, 91% HTN resolution, 75% dyslipidemia resolution, 97% joint pain resolution, and 100% sleep apnea resolution after 12 months. Abdallah et al.  indicated that HTN showed the highest resolution (88%), followed by OSAS (72%), and that the lowest resolution was shown by OA (34%).
Brethauer et al.  stated that, after LSG, DM resolved in 56% of patients with another 37% showing improvement, HTN was controlled or cured in 78% of patients, and OSAS was changed or relieved in 93% of patients. These findings are also consistent with the findings in our study, which showed that DM had the best resolution (80%), followed by HTN (75%) and OA (50%).
With regard to health related QOL, we found that the postoperative bariatric QOL score was markedly improved compared to the preoperative score and was nearly equal in the two groups. We used the QOL score described by Elrefai et al., which has a minimum of 13 and a maximum of 65 . The normal score starts at 50, and a score > 52 represents very good QOL. The bariatric QOL improvement was greater at 12 months than at 1, 3, and 6 months postoperatively, and there were no statistically significant differences between the two study groups in terms of QOL score throughout the postoperative follow-up period (p > 0.05). Bobowicz et al. reported similar results in a study employing the Bariatric analysis and reporting outcome system (BAROS), as the QOL was shown to be up-scaled to good or very good in 66% of LSG patients at 12 months . Another study by Charalampakis et al. revealed that the QOL was significantly improved postoperatively for a longer duration of follow-up (24 months). They used the obesity-specific Moorehead–Ardelt II questionnaire (MAII). The MAII score increased from − 0.40 ± 1.30 preoperatively to 1.75 ± 0.83, 2.18 ± 0.80, and 1.95 ± 0.71 at 6, 12, and 24 months postoperatively (trend p < 0.001) . Only a small number of longitudinal studies commented on the QOL after any bariatric procedure through a follow-up period of at least 2 years. Strain et al.  reported a decrease in the Impact of Weight on QOL score 1 year after LSG. D’Hondt et al. observed a trend toward weight gain and a drop in the QOL based on the BAROS score at 5 years postoperatively . Another study revealed a reduction in the mean %EWL and QOL based on the BAROS scoring between the 3rd and 5th years of follow-up . In contrast, Carlin et al. described steady QOL results from the 1st through the 5th years of follow-up .
In our study, there were neither intraoperative complications nor postoperative mortalities. The overall complication rate was 25% (24 patients) in both groups combined; major complications were encountered in only ten patients (10.41%). In Group 1, there were six patients (12.5%) with major complications: 2 patients (4.17%) developed postoperative leakage, 2 patients (4.17%) developed acute paraoesophageal intrathoracic migration of the sleeve, and two patients (4.17%) developed splenic infarction; six patients (12.5%) developed minor complications (port site infection). In Group 2, there were four patients (8.33%) with major complications: 2 patients (4.17%) developed postoperative acute bleeding and two patients (4.17%) developed intraabdominal sepsis; eight patients (16.67%) developed minor complications (port site infection). There was no significant difference between the two groups regarding the incidence of complications (25% in Group 1 vs. 25% in Group 2, p > 0.05).
Recently, the American Society for Metabolic and Bariatric Surgery reported that the mortality rate for sleeve gastrectomy varied from 0–1.2%, whereas the occurrence of morbidities ranged from 0–17.5% . In a literature review study, the mortality rate following Sleeve gastrectomy was 0.6%, and the most common complications were reoperation (4.5%), gastric leakage (0.9%), stricture formation (0.7%), pulmonary embolism (0.3%), bleeding (0.3%), delayed gastric emptying (0.3%), wound infection (0.1%), intraabdominal abscess (0.1%), trocar site hernia (0.1%), and splenic injury (0.1%) . The risk of different complications varied among authors with bleeding varying from 0–16% and gastric leakage from 0–5.5% (19,37). Leak, known to be the most frequent cause of death, varied from 0–1.7% [18, 33]. Abdalla et al. recorded postoperative gastric fistula formation in three patients (2.9%): two patients with LSG division starting 2 cm from the pylorus and one patient with division starting 6 cm from the pylorus. Several studies stated that starting the division > 5 cm from the pylorus would enhance gastric emptying by preserving the antrum and minimizing the intragastric pressure (and thereby reducing leakage). Others assumed that there was little change in the leakage rate or weight loss dependent on this item [9, 10]. The major contributor to the production of GERD or fistula at the angle of His during LSG could be too tight a stricture at the incisura angularis .
The relatively short follow-up period is one of the restrictions of the current research. Moreover, the comparatively small sample size of patients included in our work may be considered another limitation. We strongly encourage carrying out other studies with extended follow-up for a larger number of patients, preferably in a multi-institutional setting.