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ATTUALITA’ E NUOVE PROSPETTIVE IN CHIRURGIA BARIATRICA E METABOLICA Cagliari 25-27 Aprile 2013. Sleeve gastrectomy and gastric plication. Comparison of two restrictive bariatric procedures. Giorgio Bottani , MD Azienda Ospedaliera della Provincia di Pavia

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ATTUALITA’ E NUOVE PROSPETTIVE

IN CHIRURGIA BARIATRICA E METABOLICA

Cagliari 25-27 Aprile 2013

Sleeve gastrectomy and gastric plication.

Comparison of two restrictive bariatric procedures

Giorgio Bottani, MD

Azienda Ospedaliera della Provincia di Pavia

Direttore U.O.C. Chirurgia Generale

Direttore Centro di Chirurgia dell’Obesità

slide2

Mitt Romney

LSG

LGCP

We compared the results and complications of gastric plication with the sleeve gastrectomy.

slide3

Materials and Methods:

  • Afterapproval of the InstitutionalEthicsCommittee,

wehaveachieved50 gastric plication and 50 sleeve gastrectomy in twoyears (2010-2011)

with the sametechnique and the samesurgeon, plus follow-up.

  • The inclusioncriteria areASMBS

44 women and 6 men for LGCP

40 men and 10 women for LSG (averageageis 32.5 years, the mean BMI is 41 kg/m2 (LGCP) and 43kg /m2 (LSG).

slide4

Technique

Gastric plication

  • dissection of angle of His, liberation of the greater gastric curvature with a radio frequency . Enfolding of the gastric wallperformed on the greater curvature (comprising body and antrum) and performinga doublerowof extramucosalsutures from top to bottom. A bougie 32-FR or a gastrocopeisusuallyplacedby the anesthesia team into the lumen of the stomach.

Sleeve gastrectomy

  • wasdescribedbyGagner: itconsists in reducing the stomachinto a vertical tube with a volume of about 100ml or lessachievedthroughresection of the greater curvature following a lineparallel to the lesser curvature using a linearstapler. A bougie of caliber 32-FR isusuallyplacedby the anesthesia team into the lumen of the stomachalong the lesser curvature. A test withmethyleneblueisused for controlling the sealing of the suture line.
preserving his angle
PRESERVING HIS ANGLE

Anterior view after plication preserving His Angle

Talebpour et al.Annals of Surgical Innovation and Research20126:7 doi:10.1186/1750-1164-6-7

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For bothtechniquesradiologicalcontrol

in day 1 and discharge on day 2 for LGPC

and day 5 for LSG with a liquiddiet.

  • Nutritionis free from the 6th week.
  • Monitoringvisits are after 1,3,6,12,18,24 months.

Endoscopiccontrols at doneafter 6, 12 and 24 months.

slide9

Results

  • All the laparoscopic procedures were performed without conversion.
  • The mean operative time was 45 minutes for LGPC and 50 minutes for the LSG.
  • The average stay was 3 days for LGPC and 5 days for the LSG.
slide10

Complications

For the LGCP:

  • Nausea and vomiting in 20%, resolved in twoweeks.
  • A micro perforation and a stenosis of the gastric antrum (second case due to surgicalerror).
  • Onepsychopathological case withrecovery of the weight (converted to LSG) to date.
  • Mildesophagitis in twopatients.
  • Aftersixmonths no injury. Lumen size in a yearwithoutexpansion.

For the LSG

  • 1 case leak, corrected on the first daywith suture and drainage, 4 cases of GERD.
sg complication
SG Complication

Surg Obes Relat Dis. 2011 Nov-Dec; 7 (6) :749-59. 

Third International Summit: Current status of sleeve gastrectomy..

Deitel M , Gagner M , Erickson AL , Crosby RD .

Based on a survey involving 88 surgeons who had performed 19605 LSG's, complications include

staple-line leak, at a rate from 0 to 10% (mean 1.3 ± 2.0) for high leaks at the level of the gastroesophageal junction, 0 to 10% (mean 0.5 ± 1.8) for lower leaks,

0 to 40% (mean 2.0 ± 5.0) for hemorrhage,

splenic injury in 0 to 10% (mean 0.3, sd 1.3),

liver injury in 0 to 7% (mean 0.2 ± 0.9),

stricture in 0–5% (mean 0.6 ± 1.1), and other complications in 0 to 38% (mean 2.4 ± 8.4).

Mortality rate was assessed at 0.1% with a standard deviation of 0.3.

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DISCUSSIONE

  • La LGCP ha il più basso tasso di complicanze precoci tra tutte le procedure bariatrica.
  • Le complicanze sono dovuti a errori tecnici e inesperienza.
  • I controlli endoscopici dimostrano che la piega parietale diminuisce lentamente per riduzione dell'edema iniziale,
  • I risultati radiologici non hanno rivelato alcuna dilatazione significativa dopo sei mesi.
  • La % EWL ha raggiunto un soddisfacente 60% dopo 12 mesi, rapidamente senza complicanze maggiori.
  • Questa tecnica ha bisogno di ulteriori studi e di tempo, anche se l’esperienza di Talebpour dopo 12 anni è incoraggiante.
discussione
DISCUSSIONE

COMPLICANZE

  • Gli effetti di tutti i metodi restrittivi sono simili, il metodo migliore è quello con il minimo rischio di complicanze.
  • LGPG ha il minor tasso di reintervento 1%
  • SG- il 10% leakege, stenosi e malassorbimento

ORMONIL'equilibrio tra gli ormoni gastrici e l'appetito non è stato modificato dopo SG

  • La SAZIETA’ è legata alla diminuzione dello spazio-pressione intraluminale. Questo meccanismo è più evidente per la LGPG.
lgcp ewl a 10 anni
LGCP - %EWL a 10 anni

EWL after LGP,

A Mean Percentages of EWL from baseline amount during 5 years of follow up;

B Mean Percentages of EWL from baseline amount during 5 years of follow up and their variance in cases and its range as vertical lines.

conclusioni
Conclusioni

La Plicatura gastrica è efficace quanto gli altri metodi restrittivi

  • I vantaggi sono: facilità di follow-up, nessun corpo estraneo, meno costi, bassime complicanze(0,6%), o reintervento (1%), incoraggiamento psicologico e conservazione della normale fisiologia e anatomia.
  • Il metodo è reversibile, se necessario e non impedisce successive procedure malassorbitive complementari .
  • Per quanto concerne la revisional surgery, rappresenta una valida soluzione per pazienti sottoposti a bendaggio gastrico o gastroplastica verticale con insufficiente calo ponderale o recupero del peso.