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Sleeve gastrectomy and gastric plication. Comparison of two restrictive bariatric procedures Giorgio Bottani, MD Azienda Ospedaliera della Provincia di.

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Presentazione sul tema: "Sleeve gastrectomy and gastric plication. Comparison of two restrictive bariatric procedures Giorgio Bottani, MD Azienda Ospedaliera della Provincia di."— Transcript della presentazione:

1 Sleeve gastrectomy and gastric plication. Comparison of two restrictive bariatric procedures Giorgio Bottani, MD Azienda Ospedaliera della Provincia di Pavia Direttore U.O.C. Chirurgia Generale Direttore Centro di Chirurgia dell’Obesità ATTUALITA’ E NUOVE PROSPETTIVE IN CHIRURGIA BARIATRICA E METABOLICA Cagliari Aprile 2013

2 LGCP LSG We compared the results and complications of gastric plication with the sleeve gastrectomy. Mitt Romney

3 Materials and Methods: After approval of the Institutional Ethics Committee, we have achieved 50 gastric plication and 50 sleeve gastrectomy in two years ( ) with the same technique and the same surgeon, plus follow-up. The inclusion criteria are ASMBS 44 women and 6 men for LGCP 40 men and 10 women for LSG (average age is 32.5 years, the mean BMI is 41 kg/m2 (LGCP) and 43kg /m2 (LSG).

4 Technique Gastric plication dissection of angle of His, liberation of the greater gastric curvature with a radio frequency. Enfolding of the gastric wall performed on the greater curvature (comprising body and antrum) and performing a double row of extramucosal sutures from top to bottom. A bougie 32-FR or a gastrocope is usually placed by the anesthesia team into the lumen of the stomach. Sleeve gastrectomy was described by Gagner: it consists in reducing the stomach into a vertical tube with a volume of about 100ml or less achieved through resection of the greater curvature following a line parallel to the lesser curvature using a linear stapler. A bougie of caliber 32-FR is usually placed by the anesthesia team into the lumen of the stomach along the lesser curvature. A test with methylene blue is used for controlling the sealing of the suture line.

5 LGCP

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7 PRESERVING HIS ANGLE Anterior view after plication preserving His Angle Talebpour et al. Annals of Surgical Innovation and Research :7 doi: / Research2012

8 For both techniques radiological control in day 1 and discharge on day 2 for LGPC and day 5 for LSG with a liquid diet. Nutrition is free from the 6 th week. Monitoring visits are after 1,3,6,12,18,24 months. Endoscopic controls at done after 6, 12 and 24 months.

9 Results All the laparoscopic procedures were performed without conversion. The mean operative time was 45 minutes for LGPC and 50 minutes for the LSG. The average stay was 3 days for LGPC and 5 days for the LSG.

10 Complications For the LGCP:  Nausea and vomiting in 20%, resolved in two weeks.  A micro perforation and a stenosis of the gastric antrum (second case due to surgical error).  One psychopathological case with recovery of the weight (converted to LSG) to date.  Mild esophagitis in two patients.  After six months no injury. Lumen size in a year without expansion. For the LSG  1 case leak, corrected on the first day with suture and drainage, 4 cases of GERD.

11 SG Complication Surg Obes Relat Dis Nov-Dec; 7 (6) : Surg Obes Relat Dis. Third International Summit: Current status of sleeve gastrectomy.. Deitel MDeitel M, Gagner M, Erickson AL, Crosby RD.Gagner MErickson ALCrosby RD Based on a survey involving 88 surgeons who had performed LSG's, complications include staple-line leak, at a rate from 0 to 10% (mean 1.3 ± 2.0) for high leaks at the level of the gastroesophageal junction, 0 to 10% (mean 0.5 ± 1.8) for lower leaks, 0 to 40% (mean 2.0 ± 5.0) for hemorrhage, splenic injury in 0 to 10% (mean 0.3, sd 1.3), liver injury in 0 to 7% (mean 0.2 ± 0.9), stricture in 0–5% (mean 0.6 ± 1.1), and other complications in 0 to 38% (mean 2.4 ± 8.4). Mortality rate was assessed at 0.1% with a standard deviation of 0.3.

12 LGCP POSTOPERATIVE COMPLICATIONS

13 DISCUSSIONE  La LGCP ha il più basso tasso di complicanze precoci tra tutte le procedure bariatrica.  Le complicanze sono dovuti a errori tecnici e inesperienza.  I controlli endoscopici dimostrano che la piega parietale diminuisce lentamente per riduzione dell'edema iniziale,  I risultati radiologici non hanno rivelato alcuna dilatazione significativa dopo sei mesi.  La % EWL ha raggiunto un soddisfacente 60% dopo 12 mesi, rapidamente senza complicanze maggiori.  Questa tecnica ha bisogno di ulteriori studi e di tempo, anche se l’esperienza di Talebpour dopo 12 anni è incoraggiante.

14 Sleeve gastrectomy and gastric plication. Comparison of two restrictive bariatric procedures % EWL

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16 IMMAGINE ENDOSCOPICA a 1 anno

17 DISCUSSIONE COMPLICANZE Gli effetti di tutti i metodi restrittivi sono simili, il metodo migliore è quello con il minimo rischio di complicanze. LGPG ha il minor tasso di reintervento 1% SG- il 10% leakege, stenosi e malassorbimento ORMONI L'equilibrio tra gli ormoni gastrici e l'appetito non è stato modificato dopo SG La SAZIETA’ è legata alla diminuzione dello spazio-pressione intraluminale. Questo meccanismo è più evidente per la LGPG.

18 Plicated stomach after 3 years

19 LGCP - %EWL a 10 anni EWL after LGP, A Mean Percentages of EWL from baseline amount during 5 years of follow up; B Mean Percentages of EWL from baseline amount during 5 years of follow up and their variance in cases and its range as vertical lines.

20 Differenti tecniche di plicatura

21 Conclusioni La Plicatura gastrica è efficace quanto gli altri metodi restrittivi I vantaggi sono: facilità di follow-up, nessun corpo estraneo, meno costi, bassime complicanze(0,6%), o reintervento (1%), incoraggiamento psicologico e conservazione della normale fisiologia e anatomia. Il metodo è reversibile, se necessario e non impedisce successive procedure malassorbitive complementari. Per quanto concerne la revisional surgery, rappresenta una valida soluzione per pazienti sottoposti a bendaggio gastrico o gastroplastica verticale con insufficiente calo ponderale o recupero del peso.


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