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الرئيسية   |   طي المعدة الطولي (تدكيك المعدة)   |   26 October 2012 م
THE HISTORY OF THE LAPAROSCOPIC GASTRIC PLICATION
THE HISTORY OF THE LAPAROSCOPIC GASTRIC PLICATION

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THE HISTORY OF THE LAPAROSCOPIC GASTRIC PLICATION
 Mohammad Talebpour, MD
Pioneer of Gastric Plication
The increasing prevalence of morbid obesity in the developing world is a cause of great concern. As in the Western world, interventions by way of diet and exercise have not succeeded in terms of curbing this epidemic in Iran. The variable outcomes of restrictive procedures  such as the band and sleeve are not only related to surgical technique but also requires the patient to ‘work’ with their operation lifelong in terms of diet and exercise.
I developed a new restrictive bariatric surgery operation 12 years ago called the ‘laparoscopic gastric plication’ (LGP) This operation was born out of many years of doing experimental plication procedures in animal models prior to it being trialed in humans.  My initial animal models involved work in sheep. I studied 4 types of gastric restrictive procedure in sheep. These included anterior plication , direct suture of  the anterior stomach wall to the posterior wall, anterior plication with extensive wrap around the upper part of stomach and eversion of the stomach at the axis of the lesser curvature. (Figure 1).
 
 

 
Figure 1: The four types of gastric plication studied in the sheep model
 
The perceived advantages of LGP are it avoids a foreign body (cf. gastric band), does not interfere with the small bowel and is not associated with long-term vitamin/mineral deficiencies. It is also a cheaper bariatric intervention compared to the standard procedures of gastric band, gastric bypass and sleeve gastrectomy.
Eligibility criteria for gastric plication that we used are  any patient with a BMI over 40 kg/m2 or 35 kg/m2 with comorbidity. All patients were over 18 years old. However over the last 5 years since adopting the LGP technique I have performed the procedure on selected well educated adolescent patients.
The current version of LGP involves making two rows of suture lines using one thread. This causes fixation of the inverted folds of the gastric wall. I believe this  prevents any displacement of the two folds thus increasing the degree of functional restriction by adhesion of the two rows together and interfering with normal peristalsis.
My technique involves  one 10 mm and three 5 mm trocars used. The greater omentum is dissected 1 cm from the greater curvature from 3 cm from the pylorus to the Angle of His.  Two layers of the plication are done with a 00 prolene  from the fundus to within 3 cm of the pylorus ensuring extramucosal bites are taken. (Figure 2)
During the first 6 weeks postoperatively free fluids are instituted for 2 weeks, followed by pureed diet  (2 weeks) and then semi-solids for 2 weeks and then normal food. It is very important to prevent any solid food intake during first 6 weeks as the effective volume of the stomach decreases due to edema and thus carries the risk of suture site tearing by forceful contraction of stomach, secondary to solid ingestion.
 
Figure 2: Intra-operative photograph of a gastric plication
 
Results
Demographics and Outcomes
The ratio between female and male patients in my series  was 650 to 150 (81% to 19%).  Mean BMI of patients was 42.1 kg/m2 (35-59). The mean % excessive weight loss (% EWL) was 20% after one month, 35% after 2 months, 45% after 3 months, 60% after 6 months, 67% after 12 months, 70% after 24 months, 66% after 3 years, 62% after 4 years and 55% after 5 years following surgery. The % EWL peaked at 2 years to 70% with a gradual decrease to 43% by 10 years. These results are comparable to weight loss seen in  gastric band and sleeve gastrectomy patients.  The average time of follow up was 5 years (12 months -12 years).   The mean operative time was 72 (49–152) minutes and all patients were discharged from hospital after an average time of 72 hours of operation (1 – 45 days).  In my series there was about 5.5% weight regain up to 4 years after operation (26/490) but 31% regain after up to 8 years of operation (55/176) and ) and 42% after 10 years (15/35). The rate of 42% regain after 10 years in my first 35 cases of LGP was due to learning curve, one row method and a lax plication. Figure 3)
 
 
 
 
 
 
 
 
 
 
Figure 3 – Weight loss expressed as (% EWL) up to 10 years post laparoscopic gastric plication
 
Comparison Single Layer versus Two Layer Plication
The volume of stomach in a one layer plication was calculated to be 100 cc but just one half of it was effective (functional restrictive effect). The volume of stomach in a two rows plication was 50 cc (anatomic restriction) but the role of functional restriction (25cc) in this method is more prominent due to adhesion of two row sutures together. Comparing % EWL between one row and two rows LGP showed it was the same at first but higher at long term due to less anatomic volume and prominent functional restrictive effect in two rows group.  (Figure 4)
Figure 4 – Weight loss expressed as (% EWL)  using a single and double gastric plication
 
Complications
 
Vomiting and nausea was seen in all patients for at least 4 hours and the longest time with spontaneous remission was 24 days (average time=2.1 days). Epigastric pain was seen in 35% of cases for 48 hours and was relieved by antacids. Esophageal reflux was a common problem during the  first week due to high intraluminal pressure and mucosal edema after plication. If patient drink or eat more than 25 cc each time epigastric pain or esophageal reflux would occur which are important complaints (especially during first 6 months). These are two inhibitory mechanisms preventing any change in volume intake. If volume intake is in permitted dose, reflux or pain will not appear.
Postoperative technical complications were seen in 8 cases out of 800 (1%). Micro perforation occurred in three cases, intra hepatic hematoma in one case, postoperative obstruction and continuous vomiting in three cases and in the last case unusual adhesion between fundus and traumatized liver, permanent vomiting and discomfort. The rate of late (after 1 month of operation) postoperative complication after plication was zero.
 
Conclusions
 
We will need more cases and longer follow up time especially for the two row LGP cases to assess the true efficacy and durability of this operation. Certainly weight regain was seen more in patients who underwent the  single layer plication.  Complication rates can be kept low by adherence to a meticulous technique and gradual introduction of solids after 6 weeks.
I am very grateful to my patients who took part in the first human trials of the “laparoscopic gastric plication” (LGP). This has resulted in tremendous interest and practice of my procedure throughout the world. Excellent units practicing the procedure have arisen inMexico(Professor Ariel Ortiz Lagardere),Brazil(Dr. Almino Ramos),CzechRepublic(Dr. Martin Fried) and the Cleveland Clinic,USA(Professor Philip R. Schauer).

الكاتب : Mohammad Talebpour, MD Pioneer of Gastric Plication

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