Abstract

A new restrictive procedure has emerged over the last decade known as the total vertical gastric plication or greater curvature plication (GCP). After our initial experience, the original technique was modified and a new standardized procedure was registered as the Stomach Sparing Gastric Sleeve™ (SSGS). The SSGS reduces the capacity of the stomach by in-folding the greater curvature with containment sutures, creating a sleeve-like stomach. Between March 2012 and August 2015 patients that met the National Institutes of Health (NIH) criteria for gastric banding underwent treatment with the SSGS. The standardized technique requires the use of a customized fenestrated orogastric calibration device. The stomach is then imbricated or in-folded in two layers and containment non-absorbable sutures are placed longitudinally. The two layers of non-absorbable sutures are continuous starting 1 cm below the esophageal gastric (EG) junction and continued distally 3–4 cm from the pylorus spaced evenly at 1 cm intervals and sero-muscular thickness. Symmetry of anteroposterior distribution is also observed leading to the formation of a sleeve-like shaped stomach. Initial and subsequent weight (kg), body mass index (Kg/m²), excess weight loss (%EWL) and complications were recorded. Repeated measures of analysis of variance (ANOVA) were used to assess weight change. The SSGS was performed on the last 624 cases (mean age 43.1±11.6 years). The follow-up time was 3 years, with an %EWL of 56.36±21.83 during the first year and a maintenance of 49.37±30.82 by the third year of follow-up (p=<0.0005). Patients with a BMI of 20–30 Kg/m² had an EWL of 60.46% during the first 6 months after surgery and an EWL of 74.84% in the first year and a maintained EWL after 3 years of 60.45%. The surgical mean time was 45 min. There were no conversions to the open approach. A 0% mortality and 1.12% morbidity were reported. The SSGS has a weight loss comparable to other restrictive procedures, with excellent mid-term excess weight loss in the 20–30 Kg/m² BMI category. This new technique is an improvement over the original technique, as it has been modified specifically to address the complications of the original non-standardized gastric plication. The benefits of this restrictive technique are that it requires no stapling, dividing, or rerouting of the intestines, as well as no need to implant a foreign body device. The disadvantages observed were a steep learning curve and lack of a standardized technique until this publication.

Abstract

Surgery has consistently been demonstrated to be the most effective long-term therapy for the treatment of obesity. However, despite excellent outcomes with current procedures, most patients with obesity- and weight-related comorbidities who meet criteria for surgical treatment choose not to pursue surgery out of fear of operative risks and complications or concerns about high costs. Novel minimally invasive procedures and devices may offer alternative solutions for patients who are hesitant to pursue standard surgical approaches. These procedures may be used for primary treatment of obesity, early intervention for patients approaching morbid obesity, temporary management prior to bariatric surgery, or revision of bypass surgery associated with weight regain. Novel bariatric procedures can in general be divided into four categories: endoluminal space-occupying devices, gastric suturing and restrictive devices, absorption-limiting devices, and neural-hormonal modulating devices. Many of these are only approved as short-term interventions, but these devices may be effective for patients desiring low-risk procedures or a transient effect. We will see the expansion of indications and alternatives for metabolic surgery as these techniques gain approval.

Abstract

The sleeve gastrectomy has been accepted as a primary bariatric procedure. One of the most feared complications is staple line leakage. It is important to use the right staple sizes to minimize the risk of leak. Knowledge of gastric thickness is important. The goal of this study was to measure the thickness of the gastric wall after elimination of the gastric folds in the mucosa. An electronic thickness gauge was developed that measured the anterior and posterior wall of the fresh stomach specimen together at 5 points at a pressure based on the finger pressure necessary to flatten the gastric folds. Thirty-three fresh specimens were measured. The mean compression pressure was 714 grams, and no difference was found between the 5 measure points. There was a significant difference in stomach wall thickness. The gastric antrum was more than 1 mm thicker than the fundus. No difference was found between BMI groups <40Kg/m2, 40-50Kg/m2, or >50Kg/m2. No bleeding occurred, leakage occurred in 1 case. There is a significant difference in thickness of the stomach wall between the gastric fundus and the antrum. A pressure 2.5 times lower than applied in prior studies was necessary to achieve full tissue compression. Choosing thinner staple sizes for the gastric fundus might be the optimal technique for compression. However, there are several additional factors that influence the risk of staple line leaks.