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12
Case Series
complications were managed conservatively with PPI at high doses. We observed one case of transitory brachial paralysis, which regressed within 72 hours, and one case of left pneumonia, which resolved after five days of IV antibiotics.
FIGURE 6. Endoscopic view of fold invagination
Late complications. We refer to late complications as any complications observed in the patient up to six months postoperatively. Only two cases in our series developed late complications. One case of spontaneous hemoperitonium occurred six weeks after LGCP. The investigation showed corpus luteum rupture, which was treated conservatively by two units of blood transfusion. Spontaneous resorption was achieved within 15 days and monitored by magnetic resonance imaging (MRI). One case of upper gastric bleeding two months after operation by fold ulceration was observed and treated by gastroscopy and adrenaline injection with the transfusion of two units of blood.
RESULTS A B C FIGURE 7. Gastric fold edema (A–D)
Postoperative Day 1 at the gastrografin meal control.
Spontaneous resolution was achieved after four days in two cases, five days in two cases, and seven days for one case. These patients were kept at the hospital on IV line fluid administration and electrolytes. Moderate hypocalcaemia was also noted in these five cases and was treated by IV calcium gluconate. In 2007, Talebpour and Amoli concluded that fold edema is mainly due to venous stasis and operative trauma.10 We obeserved two cases of food intolerance with no evidence of obstruction on gastrografin meal. The food intolerance in these patients resolved immediately after gastroscopy at Postoperative Day 10 (gastrografin meal control was normal at Postoperative Day 1). Fold rupture and fold
herniation. Fold rupture and herniation are complications specific to LGCP. We observed one case of fold rupture and herniation in our
case series. In this patient, the upper part of the first row of the plication was broken and a large gastric pouch was formed, leading to a complete obstruction and gastric leak (Figures 8a–8c).
Leaks. One case of gastric fistula was observed at Postoperative Day 3 (Figure 9a–9c), 3cm below the gastroesophageal (GE) junction of the anterior face of the stomach with generalized peritonitis (Figure 9e). The plication was removed laparoscopically and suturing of the leak hole (Figure 9d) was made by absorbable thread. A looser plication (Figure 9f) was performed at the same time. The patient was kept on IV antibiotics for three weeks and nasogastric tube was left for three days postoperatively. Minor complications. No major complications (i.e., death, blood clots) were observed in our group of patients. Some minor complications occurred incuding minor hematemesis in seven cases and melena in two cases. These
D
One-hundred and twenty patients underwent LGCP over a period of six months at Abou Jaoude Hospital. The mean operative time was 65 minutes (ranges: 45–90) and the mean hospital stay was 36 hours. Among the treated patients, 112 patients (93.3 %) left the hospital after 24 hours, six patients (5%) were kept more than one day due to fold edema, and one patient (0.8%) was kept more than one day due to gastric leak. One case of gastric plication was done by laparotomy (conversion) and the patient was dismissed from the hospital on Postopertive Day 4.
All of the observed intraoperative complications did not change our strategy to accomplish the gastric greater curvature plication. The majority of our intraoperative complications were related to laparoscopy (trocar lesion, trocar port bleeding, pneumomediastinum), and were not specific to greater curvature plication.
Specific early complications were mainly due to the complete obstruction of the residual gastric pouch by fold edema (5%), extrinsic compression by intramural gastric hematoma (2%), or elastic gastric effect of suturing and gastric tube distortion (0.8%).
Severe early complications, notably the only case (0.8%) of gastric obstruction, were managed rapidly in our early experience by reoperation. If complete obstruction was seen after a gastrografin meal on Postopertive Day 1 with patent intraoperative methylene blue test, patients were kept on IV fluid for 3 to 5 days. Fold edema decreased
Bariatric Times • September 2011
progressively without need for any other treatment or re-intervention. Peritonitis, which occurred in one patient on Postoperative Day 3 from gastric leak, was managed laparoscopically by suturing the leak hole and cleaning the whole peritoneum cavity. Two drains were left; a looser plication was
performed. Antibiotics were given for three weeks and the patient lost 25 percent of excess weight one month postoperatively.
During Postoperative Week 1, nausea, vomiting, sialorrhoea, and minor hematamesis occurred in 40, 25, 22, and 15 percent of patients, respectively. Symptoms disappeared spontaneously within 4 to 5 days and patients returned to normal activities 5 to 7 days postoperatively. Mean total weight loss (TWL) at one, three, and six months postopertive was 11.2, 16, and 23 percent, respectively. The mean percentage of excess weight loss (EWL) at one, three, and six months postoperatively was 30.24, 43.9, and 48.58 percent, respectively. Postoperative upper endoscopy and radiologic evaluation were only performed on four patients at one and four months due to reflux symptoms. Mild to moderate esophagitis was discovered and treated by long-term PPI and antacid.
Lumen size appeared stable at four months in patients who underwent upper endoscopy. In addition, two hiatal hernia (less than 4cm) were repaired; one case of cholecystectomy was performed; two gastric bands were removed and converted into placation; and one VBG was converted into plication.
DISCUSSION/CONCLUSION
LGCP reduces the capacity of the stomach without cutting any part of it or using any device. Among all surgical procedures that reduce stomach capacity (i.e., SG, AGB, VBG) and which achieve around 50- percent EWL,7
LGCP achieved this
goal at six months in our series and others.7,10,15–17
All other current restrictive surgeries are accompanied by unsatisfactory weight loss that occurs in more than 20 percent of patients.7,15,17
This failure rate
requires surgery revision in up to 25 percent of patients.7,15,17
surgery revision rate was 1.6 percent.
VSG is a primary bariatric procedure showing midterm results of 50- to 60-percent of EWL, with improvements in comorbidities. However, these results are associated with some complications, such as esophagitis, stenosis, fistulas, and gastric leaks near the angle of His. These leaks and fistulas are reported in nearly 2 to 5 percent of all operations.16
In our series,