ORIGINAL ARTICLE
JMBSJournal of Metabolic and Bariatric Surgery J Metab Bariatr Surg 2015;4(1):19-24
Received: May 5, 2015, Revised: May 18, 2015, Accepted: May 27, 2015
Corresponding author: Sang-Moon Han, 566 Nonhyun-ro, Gangnam-gu, Seoul 135-913, Korea
Department of General Surgery, Gangnam CHA Medical Center, School of Medicine, CHA University Tel: 82-2-3468-3369, Fax: 82-2-3468-3507, E-mail: [email protected]
Copyright © 2015, The Korean Society for Metabolic and Bariatric Surgery
Short-term Experience of Laparoscopic Greater Curvature Plication in Morbidly Obese Korean Patients
Department of Surgery, Gangnam CHA Medical Center, School of Medicine, CHA University, Seoul, Korea
Ji-Sun Hong, Sang-Moon Han
Purpose:Laparoscopic greater curvature plication (LGCP) is the new emerging surgical technique for treating morbid obesity.
The short-term results of LGCP are not yet available in Korea. Materials and Methods: We retrospectively reviewed prospectively collected 18 patients’ data with over 30 kg/m2 body mass index (BMI) who underwent LGCP from January 2013 to October 2014. Fifteen of these patients who had more than 3 months of follow-up were included in this report.
LGCP was performed laparoscopically using interrupted and continuous sero-muscular suture from fundus to antrum over a 36-French bougie. Results: Mean age at the time of surgery was 33.1±7.9 years in our patients. Mean weight was 98.9±15.5 kg and mean BMI was 35.7±4.1 kg/m2 preoperatively. The percentage of excess BMI loss (%EBL) in the postoperative first, third and sixth month was 33.6±9.1, 51.6±15.4 and 64.5±18.3%, respectively. There were no 30-day peri-operative mortality and major complications including bleeding, leakage and conversion bariatric surgery. Conclusion:
These findings show that LGCP is a safe and effective weight loss option for morbidly obese Korean patients in short-term period. Randomized prospective control studies between gastric banding or sleeve gastrectomy and LGCP, are needed to confirm short-term weight loss effect and safety of LGCP in this group of patients.
Key Words: Bariatric surgery, Laparoscopic greater curvature plication, Short-term, Weight loss, Complication
INTRODUCTION
Obesity has an increasing incidence, and its treatment is a growing issue. Surgical treatment of obesity includes many types of operative procedures. Although laparoscopic greater curvature plication (LGCP) has been an evolving surgical procedure over the past years, the safety and effectiveness of LGCP are not yet clear.
The postoperative gastric shape between LGCP and laparoscopic sleeve gastrectomy (LSG) is similar. However, the weight loss effect and safety of LGCP are under investigation and exactly not known. The advantages of
LGCP include no gastric resection, physiologic food conduit, avoidance of foreign body, lower cost, immediate restriction of caloric intake and low incidence of complications [1-7]. Nevertheless, the results of LGCP in morbidly obese Korean patients are not yet available.
The aim of our study is to present short-term weight loss effectiveness and safety after LGCP in morbidly obese patients.
MATERIALS AND METHODS
After institutional review board approval, the authors
Fig. 1. Peri-operative view after first interrupted stitches.
Fig. 2. Final appearance of plicated stomach with calibration 36-French tube.
performed a retrospective review of a prospectively collected database and medical chart review of 18 patients who underwent LGCP from January 2013 to October 2014.
Eligible criteria were BMI ＞35 kg/m2 without associated co-morbid conditions, or BMI ＞30 kg/m2 with co-morbidi- ties [8,9]. Of these 18 patients, 3 patients had less than 3 months of follow-up, thus excluded from this study. The operation was performed under general anesthesia in a French position with reverse Trendelenburg. A VisiportTM Plus Optical Trocar (Covidien, Norwalk, CT, USA) was inserted in the left upper quadrant with insufflation of the abdominal cavity to a pressure of 12-15 mmHg. Three or four trocars were used. Short gastric vessels were taken down along the greater curvature of the stomach with a Harmonic scalpel (Ethicon Endo-surgery, Cincinnati, OH, USA). Dissection started 3-4 cm from the pylorus, extending cephalad, and taking the adhesions down around the fundus of the stomach in a way similar to the dissection for a sleeve gastrectomy. A 36 French bougie was inserted following the lesser curvature and was used as a guide to calibrate the plication. LGCP was created by plicating the greater curvature, applying a first row of extra-mucosal non-absorbable interrupted stitches with 2-0 Ethibond Excel (Ethicon, Inc., Somerville, NJ, USA) (Fig. 1). The distance between the sutures varied between 2.0 and 2.5 cm. This was reinforced by a second row with a non-absorbable running suture with 2-0 Ethibond or 3-0 V-LocTM (Covidien, Mansfield, MA, USA) (Fig. 2). This row was meant to strengthen the plication and prevent herniation between stitches. Plication started 2 cm from
the gastro-esophageal junction and was carried down to 3-4 cm from the pylorus. No leak test was performed. A closed suction drain was left in place. All patients had a routine gastrografin upper gastrointestinal study on postoperative day 1. If there was no gastric obstruction, patients received water and clear liquid diet, and progressed to a full liquid diet for 1 week. After liquid diet, soft diet was followed for 2 weeks, and then advanced to a regular diet on the 4th week. Follow-up visits were scheduled for every 3 months in the postoperative first year. The percentage of excess BMI loss (%EBL) is presented by dividing the change in BMI from baseline by excess BMI, which was obtained by subtracting the ideal BMI (23 kg/m2) from the actual BMI. Data are presented as either mean±standard deviation or percentages.
RESULTS
1. Demographics
Of our patients, 12 (80.0%) were female and 3 (20.0%) were male. Mean age was 33.1±7.9 years at the time of LGCP. Preoperative mean weight and BMI were 98.9±15.5 kg and 35.7±4.1 kg/m2, respectively. The patients had an average of 2.3±1.5 co-morbidities. Preoperative co-morbid conditions are presented in Table 1.
2. Weight, BMI change and excess BMI loss (EBL) Preoperative mean weight was 98.9±15.5 kg in these patients. Postoperative mean weight was 87.8±13.2 kg at
Table 1. Preoperative co-morbidities in morbidly obese patients undergoing laparoscopic greater curvature plication
Co-morbidities N (%)
Dyslipidemia 8 (53.3%)
Fatty liver 6 (72.0%)
Hypertension 5 (40.0%)
Menstrual irregularity 4 (33.3%)
Sleep apnea 4 (26.7%)
Gout 1 (6.7%)
Type 2 diabetes mellitus 1 (6.7%)
Fig. 3. Body weight loss.
Fig. 4. Body mass index change.
Fig. 5. Percentage of excess body mass index loss change.
Fig. 6. Immediate postoperative obstruction at imbricated fundus of stomach.
1 month, 81.7±12.0 kg at 3 months, and 75.9±11.0 kg at 6 months after LGCP (Fig. 3). Preoperative mean BMI was 35.7±4.1 kg/m2. Postoperative BMI was 31.7±3.9 kg/m2 at 1 month, 29.6±3.9 kg/m2 at 3 months, and 27.6±3.4 kg/m2 at 6 months (Fig. 4). The %EBL was 33.6±9.1% at 1 month, 51.6±15.4% at 3 months, and 64.5±18.3% at 6 months after LGCP (Fig. 5).
3. Postoperative complications
We investigated early complications (within 30 days postoperatively). From the total of 15 patients, 2 (13.3%) patients developed atelectasis. Most patients excluding 1 patient discharged within 48 hours after LGCP. One patient experienced immediate nausea and recurrent vomiting because of postoperative obstruction at imbricated fundus of stomach (Fig. 6). Therefore, this patient discharged on postoperative day 5 after conservative treatment. No mortality was noted during this period, and there were no major complications such as leak or bleeding.
DISCUSSION
An ideal bariatric surgery has technical simplicity, minimal invasiveness, durable long-term weight loss, resolution of co-morbidities, low postoperative complications and low re-operation rate. Many weight loss surgeries have been tried and abandoned because of poor long-term weight loss, mechanical or metabolic complications. Laparoscopic adjustable gastric banding (LAGB) is known to be the safest procedure within the peri-operative period. However, the number of LAGB performed has sharply decreased because of long-term complications and high re-operation rate [10-13]. LSG has been most commonly performed in Asia due to minimized risk of undetected gastric cancer, incredible short and mid-term weight loss, and low postoperative complications [14]. However, LSG is associated with some complications such as fistulas, leaks and stenosis [15]. For this reason, new surgical technique in similar with LSG was developed.
LGCP is a new restrictive technique that was first reported by Wilkinson and Peloso [16] in 1981. Variations of this technique have recently been described by a few surgical groups [1,3,4]. LGCP successfully reduces the gastric volume by plication of the greater curvature without the use of foreign materials or gastrectomy. But, few weight loss reports after LGCP were published at short-term period [1-7]. Talebpour and Amoli [1] reported 54% of excess weight loss (%EWL) at 6 months and 61% of
%EWL at 1 year postoperatively. Atlas et al. [6] reported 57% of %EWL at 6 months and 50.7% at 1 year follow-up.
Mui et al. [17] reported 66% of %EWL at 6 months and 60.2% of %EWL at 1 year postoperatively in Hong Kong.
Also, Shen et al. [7] reported 51.5% and 61.1% at 6 and 12 months postoperatively in China. Even though we experienced short-term follow-up after LGCP, 64.5%
excess BMI loss (EBL) at 6 months was excellent weight loss result. Generally, if patients had high BMI preoperatively, they showed low %EBL regardless of the operation procedure chosen. Because preoperative mean BMI (35.7) in our study was lower than other reports [1,7], weight loss results after LGCP might be over-estimated. Generally, ideal BMI of 25 kg/m2 is used to calculate %EWL after bariatric surgery in the western society. However, we used
ideal BMI of 23 kg/m2 to check %EBL because of different over-weight cut-off point between Korean and western society. It is difficult to compare %EWL of Western and Asian in the same way. Nevertheless, preoperative 35.7 of BMI were changed to 27.6 at 6 months postoperatively.
This BMI change represents an excellent weight loss after LGCP for Korean morbidly obese patients.
The advantages of LGCP would be that there are no resection, no foreign body, cost-effectiveness and severe complications such as leakage or hemorrhage are fewer.
Furthermore, LGCP is a relatively reversible procedure in case of failure and it mimics some of the effects of sleeve gastrectomy in terms of restriction. In spite of fewer complication rates after LGCP in short-term period, as other bariatric procedures, the complications caused by imbrications of greater curvature exist. The most common complications reported of LGCP are nausea, vomiting, and sialorrhea, although micro-leak from the suture line, gastric bleeding, obstruction, gastro-gastric hernia and porto-mesenteric thrombosis also have been reported in individual cases [4,18,19]. In our study, we experienced 1 (6.7%) patient with vomiting because of immediate postoperative obstruction. Because of it, this patient discharged postoperative day 5. To avoid immediate obstruction after LGCP, Talebpour and Amoli [1]
recommended 4-bite technique to escape the creation of a large intra-luminal septum of inverted gastric wall in fundus. Most surgeons start plication after mobilization of the gastric fundus and exposure of the left pillar of crus [4,5,17]. But, El-Geidie and Gad-el-Hak [20] recommended that leaving 2 cm below the angle of His is important step to avoid obstruction of the lower esophagus by the invaginated gastric wall at LGCP. Gastric lumen obstruction after LGCP is due to a considerable amount of edema and venous congestion that occurs in the folds postoperatively.
With the passage of time, nausea or vomiting generally disappears in LGCP patients. But, if it did not disappear for 1 week postoperatively, gastric obstruction, gastric stitch leak and gastro-gastric herniation should be evaluated.
The reason of gastro-gastric herniation after LGCP was too tight plication causing vomiting and high pressure in gastric tube. Another reason could be too wide distance between first row invaginated sutures. Therefore, we
always performed less than 2.5 cm distance between interrupted stitches and second row of continuous imbrication suture to prevent gastro-gastric herniation. If it is found at early postoperative period, reversal of gastric tube could be easily performed. But, reversal of LGCP at long-term period is very difficult due to severe adhesion.
Gastric leak at LGCP is a rare complication. Brethauer et al. [3] hypothesized postoperative gastric perforation, which included acute distention of the stomach or severe vomiting with a resultant full-thickness tear at the suture line and delayed thermal injury to the stomach that occurred during division of the short gastric vessels.
Therefore, energy based devices should not be close to gastric wall to avoid thermal injury. Although there was no bleeding or leakage in our patients, the number of patient treated is too small to make any conclusion on what the incidence might be in large numbers of patients.
The operative techniques of LGCP have been developed but not been standardized until now. Especially, the distance of the imbrications suture and starting and ending point were not standardized. As time goes on, operative technique of LGCP will be standardized. LGCP is a new novel technique. But, prospective comparative studies with other procedures are needed to evaluate the short-term efficacy of LGCP.
The limitation of our study is that it is retrospective and small in nature. Also, we did not investigate short-term co-morbidity changes after LGCP. However, our study shows that LGCP is safe and has excellent short-term weight loss for morbidly obese patients in Korea.
CONCLUSION
LGCP seems to be an effective and safe for weight loss procedure in morbidly obese Korean patients. Patients who had undergone LGCP achieved significant weight loss at 6 months postoperatively. The randomized prospective control study between LAGB and LGCP, or LSG and LGCP is needed to confirm safety, and efficacy as weight loss surgery, and improvement of co-morbidities.
CONFLICT OF INTEREST
Dr. Ji-Sun Hong and Sang-Moon Han declare that they have no conflict of interest and no relevant financial interest.
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