Clinical Outcomes of Laparoscopic Greater Curvature Plication and Laparoscopic Sleeve Gastrectomy: a Case-Matched Control Study

Trocar number and placement for laparoscopic sleeve gastrectomy and comparison of single-incision and conventional laparoscopic sleeve gastrectomy: a systematic review and meta-analysis

BACKGROUND

Conventional laparoscopic sleeve gastrectomy (CLSG) has been conducted in multiple centers for treating morbid obesity, however, there are no standard criteria for (1) placing the trocar; and (2) how many trocars should be used. Single-incision laparoscopic sleeve gastrectomy (SLSG), a newly emerged technique in 2008, has been proposed as an alternative to CLSG in recent years, however, there is no definite evidence for this.

MATERIALS AND METHODS

A systematic literature search was performed using the PubMed, Embase, Web of Science, and Cochrane Library databases for laparoscopic sleeve gastrectomy cases from January 2006 to October 2022. We then summarized the trocar numbers and placement patterns among these studies. A meta-analysis was conducted to compare the difference between SLSG and CLSG in the perioperative and postoperative indices.

RESULTS

A total of 61 studies involving 20 180 patients who underwent laparoscopic sleeve gastrectomy for treating morbid obesity were included in the systematic review, including 11 on SLSG, 35 on CLSG, and 15 studies comparing SLSG and CLSG. A systematic review showed that the trocar number varied in different CLSG studies, mainly using four or five trocars. The trocars were mainly placed in position, presenting an inverted trapezoid pattern and a left-predominant pattern. Meta-analysis showed that the operative time in the SLSG was significantly higher than that in the CLSG, and the pain Visual Analog Scale rating on postoperative day 1 in the CLSG was significantly higher than in the SLSG. There were no statistical significances in the other complications or surgical efficiency.

CONCLUSIONS

In the CLSG, the majority of the trocars were arranged in an inverted trapezoid pattern and were of the left-predominant type. Although SLSG is a feasible technique in selected patients, there is insufficient evidence to recommend its widespread use compared with CLSG. High-quality randomized controlled trials with large study populations and long follow-up periods will be required in the future.

Fatty Pancreas and Cardiometabolic Risk: Response of Ectopic Fat to Lifestyle and Surgical Interventions

Ectopic fat accumulation in non-adipose organs, such as the pancreas and liver, is associated with an increased risk of cardiometabolic disease. While clinical trials have focused on interventions to decrease body weight and liver fat, ameliorating pancreatic fat can be crucial but successful intervention strategies are not yet defined. We identified twenty-two published studies which quantified pancreatic fat during dietary, physical activity, and/or bariatric surgery interventions targeted at body weight and adipose mass loss alongside their subsequent effect on metabolic outcomes. Thirteen studies reported a significant decrease in body weight, utilising weight-loss diets (n = 2), very low-energy diets (VLED) (n = 2), isocaloric diets (n = 1), a combination of diet and physical activity (n = 2), and bariatric surgery (n = 5) including a comparison with VLED (n = 1). Surgical intervention achieved the largest decrease in pancreatic fat (range: -18.2% to -67.2%) vs. a combination of weight-loss diets, isocaloric diets, and/or VLED (range: -10.2% to -42.3%) vs. diet and physical activity combined (range: -0.6% to -3.9%), with a concurrent decrease in metabolic outcomes. While surgical intervention purportedly is the most effective strategy to decrease pancreas fat content and improve cardiometabolic health, the procedure is invasive and may not be accessible to most individuals. Given that dietary intervention is the cornerstone for the prevention of adverse metabolic health, the alternative approaches appear to be the use of weight-loss diets or VLED meal replacements, which are shown to decrease pancreatic fat and associated cardiometabolic risk.

Long-Term Outcomes of Laparoscopic Greater Curvature Plication and Laparoscopic Sleeve Gastrectomy: Critical Appraisal of the Role of Gastric Plication in Bariatric Surgery

Background and Objectives: This single-center study aimed to assess the role of laparoscopic greater curvature plication (LGCP) in bariatric surgery. Materials and Methods: Using data from our institution’s prospectively maintained database, we identified adult patients with obesity who underwent either laparoscopic sleeve gastrectomy (LSG) or LGCP between January 2012 and July 2017. In total, 280 patients were enrolled in this study. Results: The body mass index was higher in the LSG group than in the LGCP group (39.3 vs. 33.3, p < 0.001). Both groups achieved significant weight loss during the 3-year follow-up (p < 0.001). The weight-reduction rate was higher in the LSG group than in the LGCP group 6, 12, and 24 months postoperatively (p = 0.001, 0.001, and 0.012, respectively). The reoperation rate of the LGCP group was higher than that of the LSG group (p = 0.001). No deaths were recorded in either group. Conclusions: Although both the LGCP and LSG groups achieved significant weight loss over three years, the LGCP group demonstrated a lower weight-reduction rate and a higher reoperation rate than the LSG group. Thus, it is necessary to reassess the role of LGCP in bariatric surgery, particularly when LSG is a feasible alternative.

Revision of Gastric Plication to Gastric Bypass (Indications and Solutions)

BACKGROUND: Laparoscopic gastric plication (LGP) has gained increased acceptance as initial weight loss operation, but as with any other procedures, insufficient weight loss, early and late complications such as early and late strictures, gastroesophageal reflux and leak and others have been announced as an indication for revision to gastric bypass surgery as the correct solution. AIM: The aim of the study was to recognize the common indications for revision of gastric plication (GP) to RYGP and OAGB in our centers and to evaluate the outcome of treating weight regain, complications, and comorbidities. METHODS: A retrospective study conducted on 54 cases of undesirable results following gastric plication in other centers that were revised to gastric bypass procedures (RYGB and OAGB) from June 2015 to June 2018. Weight regain, gastroesophageal reflux disease not responding to medical treatment, undiagnosed hiatal hernia at surgery, post-operative leak, and strictures are the main categories included as indications for revision to gastric bypass in this study for a period of follow up to 2–5 years regarding weight loss, improvement of GERD and hiatal hernia, improvement of leak, stricture, and axial rotation of stomach. RESULTS: 54 consecutive patients included in this study previously subjected for LPG few years ago. 13 (24%) male and 41 (76%) female patients with mean age of 39.5 years ranging from (21–58) years and BMI from (41–48) Kg/m2. The main indication for revision surgery in the form of gastric bypass procedure (RYGB and OAGB) was weight regain in about 69% of cases. In addition to non-responding GERD to medical treatment (13%), hiatus hernia with plicated stomach migration to the mediastinum (3.7%), local collection secondary to leak (1.85%), stricture at site of plication (1.85%), and one case of axial rotation of the stomach (1.85%). Patient postoperatively done well and a follow-up for up to 3 years after revision surgery was uneventful. Most of our patients have good improvement regarding the inclusion criteria in our study (100% cured GERD, 90% cured leak site, about 90% cured symptomatic and radiological hiatal hernia, 100% cured after early, late strictures, and axial rotation while regarding loss of weight and least comorbidities about 88%). CONCLUSION: Although GP is an established bariatric procedure in treating and solving obesity and its complications, there are certain restrictions and difficulties that makes RYGB superior to GP.

A safety study of laparoscopic single-anastomosis duodeno-ileal bypass with gastric plication (SADI-GP) in the management of morbid obesity

Background

Bariatric surgery is more effective in the management of morbid obesity and related comorbidities than is conservative therapy. Pylorus-preserving single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-SG) is a modified duodenal switch technique. Gastric plication (GP) is an alternate to SG.

Methods

Morbidly obese (BMI of > 40, or > 35 in the presence of diabetes or prediabetes) patients were recruited and operated on to perform SADI with GP. Complications related to surgery were recorded to assess the feasibility of the procedure. Weight-loss outcomes were analysed to determine efficacy. Minnesota Multiphasic Personality Inventory 2 (MMPI-2) was recorded after 1 year of follow-up, and test scales were used to describe physiological phenomena.

Results

Seventeen middle-aged (mean: 40 years) patients were involved in our study; 15 of them were females. The mean duration of surgery was 205 min. There were no complications of conversion, death, bleeding, VTE or 30-day readmission to hospital. We did experience CD4a (pulmonary insufficiency due to chronic lung disease) and a CD3b (anastomosis leakage treated laparoscopically) complications. Vomiting occurred in three cases (CD1). Obesity-related comorbidities showed favourable resolution rates (77.8% for hypertension, 81.2% for dyslipidaemia, 100% for diabetes at the 1-year follow-up). Weight-loss outcomes were favourable (53.20 EWL%, and 35.58 TWL% at 1-year follow-up). Greater weight loss caused significantly higher levels of Depression (t(13.958) =  − 2.373; p = 0.00; p < 0.05) and Low Positive Emotions (t(13.301) =  − 2.954; p = 0.00; p < 0.05) and Introversion/Low Positive Emotionality (t(13.408) =  − 1.914; p = 0.02; p < 0.05) in MMPI-2 data.

Conclusion

According to our safety study, SADI-GP is a promising malabsorptive procedure, but a long-term high-volume case series or a randomised controlled trial is necessary to evaluate complication rates and weight-loss outcomes. Emotional dysregulation is common among bariatric surgery patients according to personality inventory data; therefore, psychological follow-up and psychotherapeutic support are necessary for weight-loss maintenance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02276-9.

Comparison Between Laparoscopic Sleeve Gastrectomy and Laparoscopic Greater Curvature Plication Treatments for Obesity: an Updated Systematic Review and Meta-Analysis

Bariatric surgery has been widely performed to treat morbid obesity. Our meta-analysis aims to provide an updated comparison between laparoscopic sleeve gastrectomy (LSG) and laparoscopic greater curvature plication (LGCP). Medline, EMBASE, Scopus, and Cochrane Central were searched. Ongoing clinical trials were identified from the clinicaltrials.gov website. References of the chosen literatures were manually reviewed for additional relevant studies. As a result, a total of 18 studies involving 1329 patients were selected. We demonstrated a significant higher excess weight loss (%EWL) after LSG at the 1-, 3-, 6-, 12-, and 18-month follow-up time points. However, no significant difference was found at 36 months. Body Mass Index Loss (BMIL) was better after LSG than LGCP at 12 and 24 months. The difference in the improvement of comorbidities (i.e., T2-DM, hypertension, and sleep apnea) did not reach statistical significance. The complications (i.e., bleeding, stenosis, leak, and abdominal pain), operative time, and length of hospital stay were comparable. More patients undergoing LGCP experienced nausea and vomiting. We obtained some different and new results compared to the previously published meta-analysis. Our meta-analysis showed significantly higher %EWL at 24 months (Z=2.08, p=0.04), significantly higher BMIL at 36 months (Z=9.11, p <0.00001), and significantly higher costs (Z=2.87, p=0.004) in the LSG group. In addition, for the first time, complications (i.e., GERD, wound infection, port-site hernia, and mortality) and improvement of dyslipidemia were compared between the two techniques. According to our pooled data, no significant differences were found in any of the above aspects. In conclusion, LSG is superior to LGCP with regard to providing effective weight loss in the short- and mid-term. LSG has a lower rate of minor complications, but was less effective when considering cost. The two procedures are similar in terms of improvement of comorbidities, major complications, operative time, and length of stay.

Laparoscopic Greater Curvature Plication for the Treatment of Obesity: a Systematic Review

BACKGROUND

During the last decade, laparoscopic greater curvature plication (LGCP) has been used as a bariatric procedure for the treatment of obesity, regarded as less invasive and less expensive than other surgical bariatric procedures. We aimed to systematically review the literature and highlight recent clinical data regarding outcomes of LGCP in the treatment of obesity.

METHODS

A comprehensive research of Pubmed database on LGCP was performed. The search was conducted on the first of May 2020 and was not limited to any date range. Outcomes of interest were surgical technique, postoperative complications, weight loss outcomes, comorbidities improvement or resolution, and revisional surgeries after technical failure or weight regain.

RESULTS

Fifty-three articles were eligible for inclusion, with 3103 patients undergoing LGCP (mean age: 13.8-55 years). Mean preoperative body mass index (BMI) ranged from 31.2 to 47.8 kg/m². Mean operative time ranged from 48 to 193 min. Length of hospital stay ranged from 0.75 to 7.2 days. Most studies provided postoperative follow-up up to 12 months. Mean percentage of excess weight loss (%EWL) ranged from 30.2 to 71.1% and 35 to 77.1% at 6 and 12 months post-LGCP, respectively. Only one study followed patients for more than 10 years and mean %EWL at 1, 5, and 10 years was 67%, 55%, and 42%, respectively.

CONCLUSION

LGCP seems to be an acceptable surgical procedure for the treatment of obesity, especially in centers having a low medical budget. However, most existing comparative studies report superiority of LSG regarding weight loss.

How Bad Is "Bad"? A Cost Consideration and Review of Laparoscopic Gastric Plication Versus Laparoscopic Sleeve Gastrectomy

BACKGROUND

Recent large-scale studies have concluded that laparoscopic sleeve gastrectomy (LSG) is superior to laparoscopic gastric greater curve plication (LGP) in weight loss outcomes and post-operative complications, but LGP is still being performed due to its purported financial advantage. Our analysis provides an investigation of cost at the time of operation, and a consideration of the financial implications of the complications and percentage of reoperation associated with each procedure.

METHODS

A systematic literature search was performed on the electronic medical databases PubMed and Embase. Extraction of data was performed using a pre-made form which included number of subjects, minor complications and rates, major complications and rates, reoperation rate, percent end weight loss, length of operating time, and length of hospital stay.

RESULTS

Twenty-eight records were included after screening for inclusion criteria, representing data from 3242 patients (2668 with LGP and 574 with LSG). Minor and major complications of LGP were documented in 28.7% and 7.2% of cases, respectively, and the rate of reoperation was 10.2%. Minor and major complications of LSG were 19.4% and 4.1%, respectively, and the rate of reoperation was 3.3%. Based on analysis of operating time and length of hospital stay means, each LGP operation was calculated to cost $10,730 USD, and LSG cost $14,074.

CONCLUSIONS

LGP has higher rates of complications and reoperation, and less %EWL compared with LSG. Despite modest initial cost benefit of LGP, when considering costs associated with the complications and reoperations, we conclude that LSG is superior to LGP in outcome and cost-effectiveness.

The effect of surgical gastric plication on obesity and diabetes mellitus type 2: a systematic review and meta-analysis

Introduction

All the bariatric procedures have evolved greatly over the past decades and laparoscopic greater curvature plication (LGCP) is one of the quite recently introduced techniques lacking systematic evaluation.

Aim

To compare and summarize the current data in the literature in regard to the effect of gastric plication on obesity and diabetes mellitus type 2.

Material and methods

The systematic review and meta-analysis was performed according to the PRISMA guidelines and registered at PROSPERO under the registration number CRD42018114314. The literature in English and German was searched using the MEDLINE (PubMed) and BJS databases for studies published in the last 10 years. A meta-analysis was performed focusing on the effects of this operation on weight loss, glycemia control and improvement of comorbidities.

Results

Mean preoperative body mass index (BMI) ranged from 34.42 to 46.3 kg/m². Most of the patients were female. The operation time was in the range from 50 to 192.23 min. Mean follow-up was from one month to 12 years, with most studies having a follow-up of less than 2 years. The postoperative BMI ranged from 28.59 to 38, with reported excess weight loss (EWL%) in the range 20-70%. Glycated hemoglobin (HbA_1c) values decreased by up to 5.1% after surgery, ranging from 5.1% to 7.5%.

Conclusions

Despite the quality of most of the included studies being low, the present meta-analysis revealed that, in the short term, gastric plication is an effective measure for weight loss, while the effect on diabetes mellitus type 2 is not statistically significant.