sadymichele

Things to consider when choosing between gastric sleeve and gastric plication

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I have researched both procedures and am having a tough time choosing between the two.  I would prefer a less invasive procedure.  I have had two drs recommend the sleeve and one recommend the plication and I can't decide.

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Dear Sadymichelle,

 

Gastric plication is a new procedure that involves folding in the lateral part of the stomach to make the stomach smaller. The procedure results in a tube-like stomach. The procedure is restrictive, and it may have hormonal effects (see final abstract below). The sleeve gastrectomy involves cutting away the lateral stomach also leaving a tube-like stomach. The sleeve gastrectomy is a restrictive procedure that has substantial gut hormone effects.

There is relatively little data regarding the long-term effects of the sleeve. Several hundred cases worldwide have been followed for 5 years, and there are so far no series that are out 10 years. The weight loss results for the sleeve and gastric bypass appear to be similar. There is even less data published regarding the gastric plication. So we just don't know the long-term effects of the plication, much less, how they will compare with the sleeve.

 

Weight loss failure after a sleeve can be treated by converting the sleeve to a gastric bypass or by performing a duodenal switch. There has been little reported on treatment of plication failure. It may be very difficult to reoperate on a plicated stomach.

 

Editorial comment: bariatric surgeons have always been trying to find a better procedure. There has been a great deal of innovation. Unfortunately, the way things work worldwide, there is very little really good comparative research that gets published. Lots of observations make it into the medical journals, but very little really scientifically sound research (randomized prospective comparison) is performed. When there is lack of solid research, one must rely on the "test of time". Does a procedure hold up over the long haul? Here is a list of restrictive procedures that have failed the "test of time": horizontal gastroplasty, vertical gastroplasty, fixed gastric bands, and endoscopic gastric plication (researchers are still working on this). The adjustable gastric band appears failing the "test of time", but is still performed for selected patients.

 

The sleeve is now the procedure that has become popular and well accepted, but we are still awaiting longer-term results. The ASMBS still considers the plication a research procedure, and in a consensus paper suggested that it should be conducted under IRB (investigational review board) supervision.

 

While the restrictive procedures have been coming and going, the gastric bypass has been performed successfully for over 40 years. The gastric bypass requires more skill to perform, and it requires more from the patient in terms of vitamin and nutrition maintenance. There are more potential long-term problems such as anastomotic ulcers and small bowel obstructions. However the long term results have been quite good with 65%, 60% and 50% excess weight loss reported at 5, 10, and 15 years respectively. There is growing evidence that the GBP is more effective than the VSG for diabetics.

 

I think that we are all anxious to have procedures that produce good results with fewer complications. However newer doesn't necessarily mean better.

 

If you are considering the plication, ask your surgeon about long-term results, complications, and how easy or hard it would be to take the plication down and convert to another procedure. Unless you are part of a research study, be very careful before selecting a plication.

 

 

 

Surg Endosc. 2013 Aug;27(8):2768-74. doi: 10.1007/s00464-013-2805-y. Epub 2013 Feb 27.
Comparison of short-term outcomes between laparoscopic greater curvature plication and laparoscopic sleeve gastrectomy.
Abstract
BACKGROUND:

Laparoscopic greater curvature plication (LGCP) is an emerging restrictive bariatric procedure that successfully reduces the gastric volume by plication of the gastric greater curvature. The aim of this prospective nonrandomized study was to compare short-term outcomes and associated complications between LGCP and laparoscopic sleeve gastrectomy (LSG).

METHODS:

From January 2011 to November 2011, a total of 39 patients were allocated to undergo either LGCP (n = 19) or LSG (n = 20). Data on the operative time, complications, hospital stay, overall cost of LSG and LGCP, body mass index loss (BMIL), percentage of excess weight loss (%EWL), loss of appetite and improvement of comorbidities were collected during the follow-up examinations.

RESULTS:

All procedures were completed laparoscopically. The mean operative time was 95.0 ± 17.4 minutes for the LGCP group and 85.5 ± 18.4 minutes for the LSG group (P = 0.107). No patient required reoperation due to an early complication. One patient in the LSG group was readmitted because of gastric stenosis. The mean hospital stay was 4.2 ± 1.9 days in the LGCP group and 3.9 ± 1.7 days in the LSG group (P = 0.595). The total cost of LSG was $7,826 ± 537 compared to LGCP ($3,358 ± 264) (P < 0.001). One year after surgery, the mean %EWL was 58.8 ± 16.7 % (n = 11) in the LGCP group and 80.0 ± 26.8 % (n = 11) in the LSG group (P = 0.038). Loss of feeling of hunger was reported in 27.3 % LGCP patients and 72.7 % LSG patients (P = 0.033) at 1 year after surgery. The comorbidities, including diabetes, sleep apnea and hypertension, were markedly improved in both groups 6 months after surgery.

CONCLUSIONS:

The short-term outcomes of our study demonstrate that compared with LSG, LGCP is inferior as a restrictive procedure for weight loss, despite its significantly smaller cost. Longer follow-up and prospective comparative trials are needed to confirm the long-term outcomes of this novel procedure and make definitive conclusions.

 

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Obes Surg. 2013 Sep;23(9):1397-403. doi: 10.1007/s11695-013-0934-y.
Is there a future for Laparoscopic Gastric Greater Curvature Plication (LGGCP)? a review of 44 patients.
Abstract
BACKGROUND:

Laparoscopic gastric greater curvature plication (LGGCP) is a new restrictive weight loss procedure.

METHODS:

Between February 2011 and June 2012, 57 patients underwent LGGCP. Thirteen had it associated with a lap band and were excluded from the study. Data was collected through routine follow-up. Demographics, complications, and percentage of excess weight loss (% EWL) were determined.

RESULTS:

Forty-four patients underwent LGGCP, 40 women and 4 men with a mean age of 40 years (range, 18-72), a mean body mass index of 38 kg/m(2) (range, 35-46). Comorbidities included 2 diabetes mellitus, 11 hypertension, 8 hyperlipidaemia, and 8 obstructive sleep apnea. The mean operative time was 106 min (range, 60-180) and mean duration of hospital stay was 18 h (range, 12-168). Operative complications included one subphrenic abscess, one gastrogastric hernia, and one acute respiratory distress syndrome. Thirty patients experienced strong restriction with nausea and vomiting for the first 10 days (79.5 %). Eleven patients (25.0 %) came back with intractable nausea and vomiting, and were hospitalized, or had their hospital stay prolonged. Four patients needed early reversal of gastric plication (9 %). There was no postoperative death. The mean postoperative % EWL was 30.6 % (n = 40), 57.0 % (n = 24), 50.7 % (n = 13) at 1, 6, and 12 months, respectively.

CONCLUSIONS:

LGGCP yields an acceptable weight loss compared to other restrictive procedures, but with a higher readmission rate for postoperative nausea and vomiting, or even reversal of plication. We advocate more studies to evaluate safety and effectiveness.

 

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Obes Surg. 2012 Oct;22(10):1633-9. doi: 10.1007/s11695-012-0723-z.
Gastric plication for morbid obesity: a systematic review.
Abstract
BACKGROUND:

Gastric plication is a new bariatric procedure. Controversies exist regarding this emerging surgery. We herein present a comprehensive review of the literature regarding gastric plication approach.

METHODS:

Advanced Pub Med search combining the MeSH terms "Gastric plication", OR "Gastric greater curvature plication" yielded 213 abstracts. Abstracts were screened for articles in English and articles on human subjects yielding 130. Further searches revealed 121 titles to be unrelated to gastric plication. The remaining nine abstracts were analyzed for their full texts. Two articles were excluded because, one was a commentary on another article, and the other was a released ASMBS policy on gastric plication. In the end, there were seven articles published on gastric plication.

RESULTS:

A total of 307 patients had undergone gastric plication. The mean operative time range was 40 to 150 min. The median length of hospital stay ranged between 1.3 and 1.9 days. In respect to excess weight loss (EWL), at 6 months, it ranged from 54 to 51 %, while at 12 months 67-53.4 %. The longest follow-up was 3 years with a mean of 57 % EWL.

CONCLUSION:

Laparoscopic gastric plication is still in its infancy. Prospective randomized studies comparing gastric plication to other well established bariatric procedures are needed to prove the reliability and metabolic effectiveness of such new procedure.

 

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JAMA Surg. 2013 Dec 18. doi: 10.1001/jamasurg.2013.3654. [Epub ahead of print]
The Effectiveness and Risks of Bariatric Surgery: An Updated Systematic Review and Meta-analysis, 2003-2012.
Abstract

IMPORTANCE The prevalence of obesity and outcomes of bariatric surgery are well established. However, analyses of the surgery impact have not been updated and comprehensively investigated since 2003. OBJECTIVE To examine the effectiveness and risks of bariatric surgery using up-to-date, comprehensive data and appropriate meta-analytic techniques. DATA SOURCES Literature searches of Medline, Embase, Scopus, Current Contents, Cochrane Library, and Clinicaltrials.gov between 2003 and 2012 were performed. STUDY SELECTION Exclusion criteria included publication of abstracts only, case reports, letters, comments, or reviews; animal studies; languages other than English; duplicate studies; no surgical intervention; and no population of interest. Inclusion criteria were a report of surgical procedure performed and at least 1 outcome of interest resulting from the studied surgery was reported: comorbidities, mortality, complications, reoperations, or weight loss. Of the 25 060 initially identified articles, 24 023 studies met the exclusion criteria, and 259 met the inclusion criteria. DATA EXTRACTION AND SYNTHESIS A review protocol was followed throughout. Three reviewers independently reviewed studies, abstracted data, and resolved disagreements by consensus. Studies were evaluated for quality. MAIN OUTCOMES AND MEASURES Mortality, complications, reoperations, weight loss, and remission of obesity-related diseases. RESULTS A total of 164 studies were included (37 randomized clinical trials and 127 observational studies). Analyses included 161 756 patients with a mean age of 44.56 years and body mass index of 45.62. We conducted random-effects and fixed-effect meta-analyses and meta-regression. In randomized clinical trials, the mortality rate within 30 days was 0.08% (95% CI, 0.01%-0.24%); the mortality rate after 30 days was 0.31% (95% CI, 0.01%-0.75%). Body mass index loss at 5 years postsurgery was 12 to 17. The complication rate was 17% (95% CI, 11%-23%), and the reoperation rate was 7% (95% CI, 3%-12%). Gastric bypass was more effective in weight loss but associated with more complications. Adjustable gastric banding had lower mortality and complication rates; yet, the reoperation rate was higher and weight loss was less substantial than gastric bypass. Sleeve gastrectomy appeared to be more effective in weight loss than adjustable gastric banding and comparable with gastric bypass. CONCLUSIONS AND RELEVANCE Bariatric surgery provides substantial and sustained effects on weight loss and ameliorates obesity-attributable comorbidities in the majority of bariatric patients, although risks of complication, reoperation, and death exist. Death rates were lower than those reported in previous meta-analyses.

 

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Can J Surg. 2013 Dec;56(6):E158-64.
Comparison of laparoscopic Roux-en-Y gastric bypass with laparoscopic sleeve gastrectomy for morbid obesity or type 2 diabetes mellitus: a meta-analysis of randomized controlled trials.
Abstract
BACKGROUND:

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most widely used bariatric procedures, and laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for treating morbid obesity is becoming more popular. We compared both techniques to evaluate their efficacy in treating morbid obesity or type 2 diabetes mellitus (T2DM).

METHODS:

We searched the Cochrane Controlled Trials Register databases, Medline, Embase, ISI databases and the Chinese Biomedical Literature Database to identify randomized controlled trials (RCTs) of LRYGB and LSG for morbid obesity or T2DM published in any language. Statistical analyses were carried out using RevMan software.

RESULTS:

Five worldwide RCTs with 196 patients in the LRYGB group and 200 in the LSG group were included in our analysis. Compared with patients who had LSG, those who had LRYGB had a higher remission rate of T2MD, lost more weight and had lower low-density lipoprotein, triglycerides, homeostasis model assessment index and insulin levels. There was no difference in the reoperation rate between the groups. However, patients treated with LRYGB had a higher incidence of complication than those treated with LSG.

CONCLUSION:

Our meta-analysis demonstrates that LRYGB is more effective than LSG for the surgical treatment of T2DM and control of metabolic syndrome. However, LSG is safer and has a reduced rate of complications. Further high-quality RCTs with long follow-up periods are needed to provide more reliable evidence.

 

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Obes Surg. 2013 Jul;23(7):980-6. doi: 10.1007/s11695-013-0893-3.
Comparison between laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding for morbid obesity: a meta-analysis.
Abstract

Bariatric surgery is now widely accepted for treatment of morbid obesity. This study compared the effects of laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) on excess weight loss (EWL) and type 2 diabetes mellitus (T2DM). PubMed and Embase were searched for publications concerning LAGB and LSG from 2000 to 2012, with the last search on August 17, 2012. EWL and T2DM improvement over 6 and 12 months were pooled and compared by meta-analysis. Odds ratios (ORs) and mean differences were calculated with 95 % confidence intervals (CIs). Eleven studies involving 1,004 patients met the inclusion criteria. Compared with LAGB, LSG achieved greater EWL. The mean percentage EWL for LAGB was 33.9 % after 6 months in six studies and 37.8 % after 12 months in four studies; for LSG, EWL was 50.6 % after 6 months and 51.8 % after 12 months in the same studies. LSG was also superior to LAGB in treating T2DM. In five studies, T2DM was improved in 42 of 68 (61.8 %) patients after LAGB and 66 of 80 (82.5 %) after LSG, representing a pooled OR of 0.34 (95 % CI 0.16-0.73) and pooled mean differences of -12.55 (95 % CI -15.66 to -9.43) and -4.97 (95 % CI -7.58 to -8.36), respectively. LSG is more effective than LAGB in morbid obesity, with higher percentage EWL and greater improvement in T2DM.

 

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Obes Surg. 2013 Dec 5. [Epub ahead of print]
Laparoscopic Greater Curvature Plication in Morbidly Obese Women with Type 2 Diabetes: Effects on Glucose Homeostasis, Postprandial Triglyceridemia and Selected Gut Hormones.
Abstract
BACKGROUND:

Laparoscopic greater curvature plication (LGCP) is an emerging bariatric procedure that reduces the gastric volume without implantable devices or gastrectomy. The aim of this study was to explore changes in glucose homeostasis, postprandial triglyceridemia, and meal-stimulated secretion of selected gut hormones [glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide-1 (GLP-1), ghrelin, and obestatin] in patients with type 2 diabetes mellitus (T2DM) at 1 and 6 months after the procedure.

METHODS:

Thirteen morbidly obese T2DM women (mean age, 53.2 ± 8.76 years; body mass index, 40.1 ± 4.59 kg/m2) were prospectively investigated before the LGCP and at 1- and 6-month follow-up. At these time points, all study patients underwent a standardized liquid mixed-meal test, and blood was sampled for assessment of plasma levels of glucose, insulin, C-peptide, triglycerides, GIP, GLP-1, ghrelin, and obestatin.

RESULTS:

All patients had significant weight loss both at 1 and 6 months after the LGCP (p ≤ 0.002), with mean percent excess weight loss (%EWL) reaching 29.7 ± 2.9 % at the 6-month follow-up. Fasting hyperglycemia and hyperinsulinemia improved significantly at 6 months after the LGCP (p < 0.05), with parallel improvement in insulin sensitivity and HbA1c levels (p < 0.0001). Meal-induced glucose plasma levels were significantly lower at 6 months after the LGCP (p < 0.0001), and postprandial triglyceridemia was also ameliorated at the 6-month follow-up (p < 0.001). Postprandial GIP plasma levels were significantly increased both at 1 and 6 months after the LGCP (p < 0.0001), whereas the overall meal-induced GLP-1 response was not significantly changed after the procedure (p > 0.05). Postprandial ghrelin plasma levels decreased at 1 and 6 months after the LGCP (p < 0.0001) with no significant changes in circulating obestatin levels.

CONCLUSION:

During the initial 6-month postoperative period, LGCP induces significant weight loss and improves the metabolic profile of morbidly obese T2DM patients, while it also decreases circulating postprandial ghrelin levels and increases the meal-induced GIP response.

 

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