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
LGCP
LSG
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.
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
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.