الفهرس 
OBESITYOnly 14 pages are availabe for public view
 |  | from | 165 |  |  |
| | | from | 165 | | |
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) 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. (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 Amo1i(236) have published the largest
series to date using the laparoscopic GCF’ 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 reexploration.
In the study of Brethauer, on 15 patients, of them 9
underwent AP gastric plication and 6 underwent GCP. 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 state 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.