Gastric greater curvature plication combined with Nissen fundoplication in the treatment of gastroesophageal reflux disease and obesity

GASTRIC PLICATION ASSOCIATED WITH FUNDOPLICATION IN INDIVIDUALS WITH CLASS I OBESITY AND GASTROESOPHAGEAL REFLUX DISEASE: WEIGHT LOSS OUTCOMES, REFLUX-RELATED SYMPTOMS, ENDOSCOPIC AND pH MONITORING FINDINGS

BACKGROUND

The association of gastric plication with fundoplication is a reliable option for the treatment of individuals with obesity associated with gastroesophageal reflux disease.

AIMS

To describe weight loss, endoscopic, and gastroesophageal reflux disease-related outcomes of gastric plication with fundoplication in individuals with mild obesity.

METHODS

A retrospective cohort study was carried out, enrolling individuals who underwent gastric plication with fundoplication at a tertiary private hospital from 2015-2019. Data regarding perioperative and weight loss outcomes, endoscopic and 24-hour pH monitoring findings, and gastroesophageal reflux disease-related symptoms were analyzed.

RESULTS

Of 98 individuals, 90.2% were female. The median age was 40.4 years (IQR 32.1-47.8). The median body mass index decreased from 32 kg/m2 (IQR 30,5-34) to 29.5 kg/m2 (IQR 26.7-33.9) at 1-2 years (p<0.05); and to 27.4 kg/m2 (IQR 24.1-30.6) at 2-4 years (p=0.059). The median percentage of total weight loss at 1-2 years was 7.8% (IQR -4.1-14.7) and at 2-4 years, it was 16.4% (IQR 4.3-24.1). Both esophageal and extra-esophageal symptoms showed a significant reduction (p<0.05). A significant decrease in the occurrence of esophagitis was observed (p<0.01). The median DeMeester score decreased from 30 (IQR 15.1-48.4) to 1.9 (IQR 0.93-5.4) (p<0.0001).

CONCLUSIONS

The gastric plication with fundoplication proved to be an effective and safe technique, leading to a significant and sustained weight loss in addition to endoscopic and clinical improvement of gastroesophageal reflux disease.

Innovative Bariatric Procedures and Ethics in Bariatric Surgery: the IFSO Position Statement

With the rise in obesity and bariatric procedures worldwide, there has been a surge in new and innovative procedures that has been increasingly offered to patients. In this position statement, IFSO highlights the importance of surgical ethics in innovation and when offering new procedures. Furthermore, the task force reviewed the current literature to describe which procedures can be offered as mainstream outside research protocols versus those that are still investigational and need further data.

A laparoscopic one anastomosis gastric bypass with wrapping versus nonwrapping fundus of the excluded part of the stomach to treat obese patients (FundoRingOAGB trial): study protocol for a randomized controlled trial

BACKGROUND

Laparoscopic one anastomosis gastric bypass (LOAGB) is a simple variation of gastric bypass and has gained worldwide popularity with clinical outcomes similar to laparoscopic Roux-en-Y gastric bypass (LRYGB) for weight loss and management of comorbidities. However, biliary reflux to the esophagus negates the benefits of LOAGB. In addition, weight gain after LOAGB and after LRYGB is a major problem in bariatric surgery. The aim of this article is to describe the design and protocol of a randomized controlled trial comparing the outcomes of two methods of LOAGB: experimental method with wrapping versus standard method nonwrapping fundus of the excluded part of the stomach to prevent weight regain and biliary reflux after LOAGB.

METHODS

The study was designed as a single-center prospective, interventional, randomized controlled trial. Masking: None (open label). Allocation: randomized. Enrollment: 100 obese patients. The relevant ethics committee approved the trial protocol. The endpoints (body mass index, bile reflux in the esophagus, other reflux symptoms) will be assessed presurgery and postsurgery (12, 24, and 36 months postoperatively).

DISCUSSION

With its 3-year follow-up time, this RCT will provide important data on the impact of wrapping the fundus of the excluded part of the stomach to prevent weight regain and biliary reflux after LOAGB.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04834635 . Registered on 8 April 2021.

A laparoscopic one anastomosis gastric bypass with wrapping versus nonwrapping fundus of the excluded part of the stomach to treat obese patients (FundoRingOAGB trial): study protocol for a randomized controlled trial

Background

Laparoscopic one anastomosis gastric bypass (LOAGB) is a simple variation of gastric bypass and has gained worldwide popularity with clinical outcomes similar to laparoscopic Roux-en-Y gastric bypass (LRYGB) for weight loss and management of comorbidities. However, biliary reflux to the esophagus negates the benefits of LOAGB. In addition, weight gain after LOAGB and after LRYGB is a major problem in bariatric surgery.

The aim of this article is to describe the design and protocol of a randomized controlled trial comparing the outcomes of two methods of LOAGB: experimental method with wrapping versus standard method nonwrapping fundus of the excluded part of the stomach to prevent weight regain and biliary reflux after LOAGB.

Methods

The study was designed as a single-center prospective, interventional, randomized controlled trial. Masking: None (open label). Allocation: randomized. Enrollment: 100 obese patients. The relevant ethics committee approved the trial protocol.

The endpoints (body mass index, bile reflux in the esophagus, other reflux symptoms) will be assessed presurgery and postsurgery (12, 24, and 36 months postoperatively).

Discussion

With its 3-year follow-up time, this RCT will provide important data on the impact of wrapping the fundus of the excluded part of the stomach to prevent weight regain and biliary reflux after LOAGB.

Trial registration

ClinicalTrials.govNCT04834635. Registered on 8 April 2021.

Reflux After Sleeve Gastrectomy: An Update

Background: Modifications of gastric anatomy, function, and of the esophagogastric junction secondary to sleeve gastrectomy (SG) can worsen the symptoms of gastroesophageal reflux disease (GERD). Its late diagnosis and poor treatment can lead to serious complications. In recent years, attempts have been made to optimize preoperative studies and improve surgical techniques to prevent this problem. The aim of this study was to update on the presence of GERD and their symptoms post-SG. Methods: A literature review of articles based on randomized clinical trials on the presence of GERD after SG was carried out, in a period of 10 years. Results: A result of 336 articles was obtained, of which 327 were discarded and 9 were included. The variables of GERD post-SG were analyzed according to their symptoms ("improved," "worsened," and "unchanged"), "remission," or appearance "de novo." Conclusion: GERD is a frequently associated pathology in obese patients. Several authors reported that symptoms worsen after SG, and has been diagnosed de novo. The application of exhaustive preoperative studies and a correct surgical technique could reduce its incidence.

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 (HbA1c) 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.

Unusual complication after laparoscopic Nissen fundoplication

We describe a rare complication of Laparoscopic Nissen Fundoplication in the presence of a Gastric greater curvature Plication (LNFGP). An overweight 64-year-old woman was admitted for severe abdominal pain, dysphagia and fever 2 weeks after a Nissen fundoplication. She had pneumoperitoneum on scanner. At laparoscopy, we found a generalized peritonitis secondary to a perforated Nissen wrap in the presence of a gastric greater curvature plication. Gastric bypass and sleeve gastrectomy can be irrelevant in case of moderately and severely obese patients with gastroesophageal reflux disease. Four studies have investigated the risks and rewards of the LNFGP as an alternative. Only one case of leakage has been reported. We present another severe complication: the pylorus stenosis caused by a plication performed too close to the pylorus, causing gastric dilatation in the presence of the wrap, leading to wrap perforation.

Laparoscopic Gastric Greater Curvature Plication: Intermediate Results and Factors Associated with Failure

BACKGROUND

Laparoscopic gastric greater curvature plication (LGGCP) is a novel bariatric procedure. Few studies have presented intermediate or long-term results. The aim of this prospective study was to investigate intermediate results and factors associated with failure to achieve satisfactory weight loss after LGGCP.

METHODS

Between October 2011 and November 2013, 61 patients underwent LGGCP and were followed up to 36 months after operation. Demographics, comorbidities, complications, and percentage of excess body mass index loss (%EBMIL) were analyzed. Logistic regression analysis was used to determine independent risk factors for weight loss failure 3 years after LGGCP.

RESULTS

Forty-eight women and 13 men with an average age of 47.7 ± 10.3 years and preoperative BMI of 46.3 ± 5.8 underwent LGGCP. Postoperative complications were observed in three patients (4.9%) and two of them (3.3%) underwent reoperations. Follow-up rate was 95%, 91.7, and 88.3% after 1, 2, and 3 years, respectively. Average %EBMIL after 1 year was 47.25 ± 21.6, 44.8 ± 25.9 after 2 years, and 41.9 ± 25.6 after 3 years. Gastroscopy 3 years after LGGCP demonstrated intact plication fold in 55% of cases. Preoperatively, GERD was present in 46% of patients. Prevalence of GERD 3 years after LGGCP was 34.6%. Remission rates of type 2 diabetes mellitus and hypertension were 27.8 and 38.3%, respectively. Higher postoperative hunger sensation was found to be an independent factor (OR 1.6, 95% 1.141-2.243; p = 0.002) associated with unsatisfactory weight loss after LGGCP.

CONCLUSIONS

Patients with LGGCP had postoperative complication rate 4.9% and achieved only modest weight loss after 3 years. Increased hunger was an independent risk factor associated with unsatisfactory weight loss after LGGCP. Long-term follow-up data are needed to define the role of LGGCP in the treatment of morbid obesity.