LAPAROSCOPIC GASTRIC PLICATION IN MANGEMENT OF MORBID OBESITY

Abstract

The field of bariatric surgery is continually evolving. Since the introduction of surgical procedures to induce weight loss, many different operations have been tried and abandoned owing to the poor long-term weight loss and/or metabolic or mechanical complications. During the past decade, the use of sleeve gastrectomy has gained popularity, and it has become widely accepted as a primary bariatric operation, as well as a first-stage operation for high-risk patients. Five-year data are now emerging that support the durability of sleeve gastrectomy.(237) The creation of a long staple line during sleeve gastrectomy can lead to complications, such as leaks and bleeding, and the irreversibility of this operation has been a detraction for some surgeons and patients. The gastric plication operations are intended to mimic some of the effects of sleeve gastrectomy (gastric restriction) without the same degree of risk. The initial procedure concept of plicating the anterior stomach was intriguing, because it did not require division of the short gastric vessels or mobilization of the greater curvature and could potentially reduce the risk to the patient. The GCP procedure does require division of the short gastric vessels, but it does not require stapling or resection and therefore might have some advantages compared with sleeve gastrectomy. The mechanisms of GCP have not yet been studied. Because gastric resection is not performed, it is unlikely that the ghrelin levels will decrease as they do with sleeve gastrectomy. Our subjective clinical experience with the present small group of patients has demonstrated reasonably good hunger control but to a lesser degree than what we have observed after sleeve gastrectomy. Patients have reliably reported early satiety during meals and pain with any overeating. As experience increases with this procedure, mechanistic studies will be needed with an emphasis on gut hormone and gastric emptying changes. These concepts were initially evaluated by Fusco et al.(238, 239) in a rat model. In the initial study, 30 Wistar rats were divided into 3 groups (sham anesthesia, sham laparotomy, and greater curvature gastric plication). The investigators demonstrated a significant decrease in weight gain in the greater curve plication group at 21 days. Fusco et al.(238, 239) this research with another rat study in which they compared 10 rats that had undergone GCP and 10 rats that had undergone AP without division of the greater curve vessels. They did not find a significant difference at 28 days between the 2 groups in their weight gain or epididymal fat pad size. Gastric plication relies on serosal adhesion formation within the fold to maintain durability. Menchaca et al.(240) have demonstrated short-term durability and fibrous serosal apposition in gastric folds created in a canine model using a variety of suture materials and fasteners. This preclinical work was a precursor to our current pilot clinical study. Ramos et al.(6) have recently reported their results for 42 patients who underwent laparoscopic GCP. The mean operative time was 50 minutes (range 40-100), and the mean hospital stay was 36 hours. No intraoperative complications occurred, and all patients experienced a % EWL of _20% after 1 month. The mean % EWL was 62% (range 45-77%) in 9 patients after 18 months.(6) A study by Sales reported 69.6% EWL at 1 year in 100 patients. (That study included