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14
Case Series
Bariatric Times • September 2011
A
B
C FIGURE 8. Laparoscopic view of fold rupture (A); Fold rupture on gastrografin meal (B); and computed tomography scan scan showing fold rupture (C).
A
B
C
D
In our case series, gastric leak rate was 0.8 percent (one patient) and reoperation for complete obstruction rate was 0.8 percent (one patient).
Physiological concepts of LGCP are similar to VSG, which produces a smaller gastric pouch by folding the great curvature of the stomach, the fundus, the corpus, and the antrum. By folding and fixing the fundus, we have noticed less postoperative nausea and vomiting. Clinical reports on LGCP demonstrate satisfactory EWL up to 65 percent.15
E
Although the patent test made intraoperatively does not exclude the possibility of fold edema and complete obstruction of the residual gastric space, we continued performing this test to exclude mechanical obstruction after intragastric tube removal (elastic gastric effect suturing can cause complete collapse of residual lumen) and gastric distortion.
In our series,
we observed that early complications occurred less frequently than in other procedures (no cutting, no anastomosis, good calibration over a 32 French tube). It is early to compare results on EWL, but we can say that early complications are less frequent (0.8% leak rate) and less severe than other procedures.18
All bleeding cases were
managed intraoperatively and no postoperative bleeding occured. Our postoperative bleeding revision was nearly zero percent. This may be due to many factors (e.g., no gastric section, hemostasis control of trocar port was made at low peritoneal pressure after valsalva maneuver). In all cases, no drain was left in the operative site (hemostasis was performed by bipolar instrument).
In our case series we found that fold edema was the most frequent complication (5%) specific to LGCP. It is easy to treat and regresses spontaneously within few days; however, it prolongs the patient's hospitalization up to five days.
Leak after LGCP in our series was due to the following: 1) trauma due to the manipulation of the stomach when performing the LGCP and 2) early vomiting effort, which can cause rupture of stitches or herniation of the fold between stitches, thus leading to a leak by gastric distention. Fixation of the fold occurs by suturing the gastric tissue between the point of entry of the needle at the posterior gastric wall and the point of exit of the needle at the anterior gastric wall in each point. This can reduce the incidence of leak and the fixation of the fundus can reduce the incidence of postoperative nausea and vomiting. Leaks after LGCP are much easier to manage than
F FIGURE 9. Gastrografin meal showing gastric leak (A); Leak hole laparoscopic view (B,C); Suturing (D); Fold, rupture, leak, and peritonitis (E); and looser plication (F). those occurring after VSG and RYGB7,10 because
LGCP is reversible, and there is enough gastric tissue to close the leak hole. Performing a new loose plication in case of peritonitis for the leak near the angle of His is feasible but challenging. Simple suturing of the gastric leak hole with the removal of the plication is another safe alternative.
CONCLUSION
Compared to other restrictive bariatric procedures, LGCP is a feasible, safe, and effective procedure for short-term EWL with low complication rates. Safety, cost efficiency, and reversibility are the main decisive arguments in patient choice when choosing a restrictive procedure. Long-term results and more studies are needed to answer frequently asked questions by surgeons and patients about long-term results and weight regain after LGCP.
REFERENCES
1. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus
Development Conference Statement. Am J Clin Nutr. 1992;55(2 Suppl):615S–619S.
2. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-