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

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• 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.

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LGCP
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(No Transcript)
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PRESERVING HIS ANGLE
Anterior view after plication preserving His
Angle Talebpour et al. Annals of Surgical
Innovation and Research 2012 67
doi10.1186/1750-1164-6-7
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• 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.

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• 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.
•  

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• 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.

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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 05 (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.

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LGCP POSTOPERATIVE COMPLICATIONS
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• 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 lesperienza di Talebpour dopo
  12 anni è incoraggiante.

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Sleeve gastrectomy and gastric plication.
Comparison of two restrictive bariatric
procedures
EWL
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EWL
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IMMAGINE ENDOSCOPICA a 1 anno
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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
• ORMONIL'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.

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Plicated stomach after 3 years
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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.
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Differenti tecniche di plicatura
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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.