Sleeve gastrectomy and gastric plication. ATTUALITA’ E NUOVE PROSPETTIVE IN CHIRURGIA BARIATRICA E METABOLICA Cagliari 25-27 Aprile 2013 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

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

Materials and Methods: After approval of the Institutional Ethics Committee, we have achieved 50 gastric plication and 50 sleeve gastrectomy in two years (2010-2011) 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).

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.

LGCP

PRESERVING HIS ANGLE Anterior view after plication preserving His Angle Talebpour et al. Annals of Surgical Innovation and Research 2012 6:7 doi:10.1186/1750-1164-6-7

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 6th week. Monitoring visits are after 1,3,6,12,18,24 months. Endoscopic controls at done after 6, 12 and 24 months.

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.  

Nausea and vomiting in 20%, resolved in two weeks. 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.

SG Complication Surg Obes Relat Dis. 2011 Nov-Dec; 7 (6) :749-59. Third International Summit: Current status of sleeve gastrectomy.. Deitel M , Gagner M , Erickson AL , Crosby RD . Based on a survey involving 88 surgeons who had performed 19605 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.

LGCP POSTOPERATIVE COMPLICATIONS

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.

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

% EWL

IMMAGINE ENDOSCOPICA a 1 anno

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.

Plicated stomach after 3 years

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.

Differenti tecniche di plicatura

La Plicatura gastrica è efficace quanto gli altri metodi restrittivi 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.