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10
Case Series
Early Complications of 120 Laparoscopic Greater Curvature Plication
by YOUSSEF ANDRAOS, MD; DANY ZIADE, MD; RANA ACHCOUTY, MD; and MARIETTE AWAD, PhD
2011;8(9):10–15 FIGURE 2. Final laparoscopic view of the plicated stomach. ABSTRACT
Reduction of gastric volume is traditionally the primary mechanism by which patients can lose weight safely. Weight loss is made possible by different procedures, including sleeve gastrectomy, vertical banding gastroplasty, and perigastric ring. Since the success rate of these procedures is variable and the complications associated with them are severe, laparoscopic greater curvature plication is emerging as an alternative, safe option for reduction of the gastric volume. In this case series, the authors discuss the first 120 cases performed at Hospital Abou Jaoude, Beirut, Lebanon, since December 2010. The initial results as well as early complications and management are discussed.
KEY WORDS
Laparoscopic greater curvature plication, vertical banding gastrectomy, vertical sleeve gastrectomy, gastric bypass, gastric plication, gastric imbrication, excess weight loss, obesity
Continued from page 1 Complications in AGB, VSG,
RYGB, and DS are due to negative pressure in the subphrenic region (continuous aspiration), high intragastric lumen pressure, stenosis, and obstruction of the gastric tube, all of which can lead to reoperation and may even cause death.15–18
This
case series highlights the early complications of laparoscopic greater curvature plication (LGCP), a new restrictive bariatric surgical technique. LGCP reduces the size of the stomach without the use of an implant or gastric resection, unlike other bariatric procedures.
METHODS
The present case series was conducted using the National Institute of Health's (NIH)1
inclusion
criteria for bariatric surgery. This criteria states that patients with a body mass index (BMI) of 40kg/m2 more, or a BMI of over 35kg/m2
or with
at least one comorbidity, can benefit from weight reduction via gastric restrictive surgeries. United States Food and Drug Administration (FDA) approval of AGB performed with the Lap-Band (Allergan, Irvine, California) in patients with a BMI of 40kg/m2
TECHNIQUE or more or a BMI of 30kg/m2
Positioning. A standard position on the operative table was adopted for all patients. Patients were placed under general anesthesia in an anti- Trendlenburg position at 30-degree French position (operator between legs) and two assistants one each side of the patient.
All patients underwent a multidisciplinary evaluation by an endocrinologist, cardiologist, psychologist, nutritionist, and pneumologist, as well as blood and barium meal tests. The case series also received the approval of the local ethics committee at Abou Jaoude Hospital in Beirut, Lebanon. From December 2010 to June 2011, a total of 120 patients underwent LGCP. This case series included 40 men and 80 women, with a mean age of 36 years (range 18–58 years) and mean BMI 40.4kg/m2 (range 30–63kg/m2
or more and one or more obesity- related comorbid conditions was also included selection of patients for surgery.2
).
All complications were monitored and recorded intraoperatively through to the end of the first month. The anesthesiologist and the Committee of Morbidity at Abou Jaoude Hospital monitored all patients postoperatively.
A five-trocar port technique was used for all patients except for those with a small left liver for whom a four-trocar technique was adopted (Figure 1). The operation began with an 18mmHg pneumoperitoneum, which was created at the palmer's point on the upper left quadrant. The first trocar of 10mm was placed 15cm from the xiphoid process and 2cm left to the midline for the 30- degree laparoscope. A second 10mm trocar was inserted at the upper left quadrant on the midclavicular line. A third 5mm trocar was inserted on the left flank at the anterior axillary line. A fourth 5mm trocar was inserted at the xiphoid process on the left of the hepatic falciform ligament. Finally, a fifth 5mm trocar was inserted in the upper right quadrant at the midclavicular line. We began the procedure by lifting the left liver lobe and fixing it by a grasp (EndoCinch,™
Davol, A
Bard Company, Warwick, Rhode Island) attached to the anterior part of the left crus. Then, the greater sac was entered by dissecting the greater curvature between the gastric body and the antrum at the horizontal branch of the crow's feet. The posterior gastric wall was held up and the body of the stomach was freed from posterior attachment, the gastrosplenic short vessels, the omentum (without the necessity to dissect the left crus), and the angle of His. The same maneuver was achieved on the greater curvature vessels distally, and stopped 3cm before the pylorus. Posterior gastric adhesions near the lesser curvature were not dissected to prevent the distortion of the new stomach. Gastric plication was created by the invagination of the greater curvature over a 32 French tube.
It is important to note that the first point of the first row must be imbricated to fix the whole fundus in order to prevent fold invagination and intraesophagal fold migration.
For this purpose, a total gastric point was made.
The first row was stopped 3cm before the pylorus. In the second row, we used nonabsorbable 2/0 thread, which fixed the first row and gave the final shape and volume of the imbricated stomach. The distance between each point was 2 to 3cm from the great curvature anteriorly and posteriorly in the first and the second row with the midline fixed at each point.
Additional separated stitches were used in some cases when the distance between stitches was larger than 2cm. This was performed in order to prevent fold herniation between stitches. In four reoperation cases (two operations following band removal and two operations following vertical banding gastrectomy), the gastric tissue was thicker and additional separated stitches were used The final aspect of the stomach was shaped like a small J as in SG procedures, slightly larger but full from the inside and fixed (Figure 2). At the end of the operation, the gastric tube was removed. Leak and patent lumen tests were performed in all cases with 50 to 100mL of diluted methylene blue. Hemostasis was verified at the end of all operations. The anesthesiologist verified that patients' blood pressure before exuflation was above the pneumoperitoneum pressure, which was decreased to 10mm of mercury. Trocars were removed from the abdominal wall but kept inserted in the subcutaneous fat. If no bleeding occurred, the residual
pneumoperitonium was aspirated and no drain was placed at the end of the operation. Six hours postoperatively, the patients were asked to walk.
At Postoperative Day 1, patients were given gastrografin meal. If no obstruction or leaks were noticed, the patients were discharged from the hospital. Liquid was given to all
Bariatric Times • September 2011
Bariatric T
imes.