الفهرس 
ObesityOnly 14 pages are availabe for public view
 |  | from | 163 |  |  |
| | | from | 163 | | |
Abstract
The field of bariatric surgery is continually evolving. Since the introduction of surgical procedures to induce weight loss, many different operations have been tried and abandoned owing to the poor long-term weight loss and/or metabolic or mechanical complications. During the past decade, the use of sleeve gastrectomy has gained popularity, and it has become widely accepted as a primary bariatric operation, as well as a first-stage operation for high-risk patients. Five-year data are now emerging that support the durability of sleeve gastrectomy.(237) The creation of a long staple line during sleeve gastrectomy can lead to complications, such as leaks and bleeding, and the irreversibility of this operation has been a detraction for some surgeons and patients. The gastric plication operations are intended to mimic some of the effects of sleeve gastrectomy (gastric restriction) without the same degree of risk. The initial procedure concept of plicating the anterior stomach was intriguing, because it did not require division of the short gastric vessels or mobilization of the greater curvature and could potentially reduce the risk to the patient. The GCP procedure does require division of the short gastric vessels, but it does not require stapling or resection and therefore might have some advantages compared with sleeve gastrectomy. The mechanisms of GCP have not yet been studied. Because gastric resection is not performed, it is unlikely that the ghrelin levels will decrease as they do with sleeve gastrectomy. Our subjective clinical experience with the present small group of patients has demonstrated reasonably good hunger control but to a lesser degree than what we have observed after sleeve gastrectomy. Patients have reliably reported early satiety during meals and pain with any overeating. As experience increases with this procedure, mechanistic studies will be needed with an emphasis on gut hormone and gastric emptying changes. These concepts were initially evaluated by Fusco et al. (238,239) in a rat model. In the initial study, 30 Wistar rats were divided into 3 groups (sham anesthesia, sham laparotomy, and greater curvature gastric plication). The investigators demonstrated a significant decrease in weight gain in the greater curve plication group at 21 days. Fusco et al. (238,239) continued this research with another rat study in which they compared 10 rats that had undergone GCP and 10 rats that had undergone AP without division of the greater curve vessels. They did not find a significant difference at 28 days between the 2 groups in their weight gain or epididymal fat pad size. Gastric plication relies on serosal adhesion formation within the fold to maintain durability. Menchaca et al. (240) have demonstrated short-term durability and fibrous serosal apposition in gastric folds created in a canine model using a variety of suture materials and fasteners. This preclinical work was a precursor to our current pilot clinical study. Ramos et al.(6) have recently reported their results for 42 patients who underwent laparoscopic GCP. The mean operative time was 50 minutes (range 40–100), and the mean hospital stay was 36 hours. No intraoperative complications occurred, and all patients experienced a %EWL of _20% after 1 month. The mean %EWL was 62% (range 45–77%) in 9 patients after 18 months.(6) A study by Sales reported 69.6% EWL at 1 year in 100 patients. (241) That study included patients with a lower BMI, with 69% of patients having a preoperative BMI of _45 kg/m2 and 25% having a BMI of _35 kg/m2. No major complications or mortality was reported in that series.(241) Talebpour and Amoli(236) have published the largest series to date using the laparoscopic GCP technique. In their report, the investigators described a slightly more restrictive GCP procedure than was performed in our present study. They reported the results from 100 patients who had undergone GCP, with a mean age of 32 years and a mean preoperative BMI of 47 kg/m2 (range 36–58). The mean %EWL loss at 1, 6, 12, 24, and 36 months was 21.4%, 54% (72 cases), 61% (56 cases), 60% (50 cases), and 57% (11 cases), respectively. The average follow-up was 18 months. The mean operative time was 98 minutes (range 70–152), and the mean length of stay was 1.3 days (range 1–4). Nausea and vomiting were the most common complications. The reoperation rate was 2.6% in their series (1 suture line leak, 1 prepyloric perforation, 1 liver abscess, and 1 kinking of the stomach requiring revision), with no late complications. (236) Their study has clearly demonstrated that gastric perforation or leak from the suture line can occur and that this type of procedure cannot eliminate these risks completely. The possible mechanisms for postoperative gastric perforation include acute distension of the stomach or severe vomiting with a resultant full-thickness tear at the suture line, as well as delayed thermal injury of the stomach that occurs during division of the short gastric vessels, particularly if the attachments to the upper pole of the spleen were very short. Therefore, the possibility of gastric leak must be considered after these operations if a patient develops any signs of infection or early sepsis. The concern for a gastric leak should prompt a radiographic evaluation or re-exploration. In the study of Brethauer, on 15 patients, of them 9 underwent AP gastric plication and 6 underwentGCP. The AP procedure did not result in any major complications. The weight loss for this procedure in its current form at 1 year (23% EWL), however, would not justify the risk of surgery for the morbidly obese patient. The patients did have encouraging weight loss initially (and 2 have had sustained weight loss), but the remaining volume of the posterior stomach after only the anterior surface was plicated did not provide a sustained effect. The failure of 4 patients in the AP group to return for the 1-year endoscopic evaluation was likely because of a poor weight loss result. No patient in the AP group requested reoperation or conversion to another procedure. Revisional options for these patients would include repeat plication to achieve improved restriction, revision to sleeve gastrectomy, or conversion to gastric bypass. Brethauer believes that conversion to Roux-en-Y gastric bypass would be the optimal choice and would be technically feasible. (5) The study was limited to patients with a BMI of 35–50 kg/m2. Results states that the GCP is an effective procedure in this BMI range.
Similar to other bariatric surgery options, patient preference, expectations, and risk tolerance play important roles in the procedure selected. GCP does offer rapid weight loss without gastric resection or an implanted device, and this is likely to appeal to many patients.
In conclusion, LGCP is a promising bariatric procedure and the present trial demonstrates it to be feasible, safe, and effective in the short term when applied to morbidly obese patients. Longer follow-up and prospective comparative trials are needed in order to broaden the acceptance of this promising procedure