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Management of gastric fold herniation after laparoscopic adjustable gastric banded plication: a single-center experience
Surgery for Obesity and Related Diseases ] (]]]]) ]]]–]]]
Original article
Management of gastric fold herniation after laparoscopic adjustable gastric banded plication: a single-center experience Po-Chih Chang, M.D.a,b,c, Anshuman Dev, M.D.a, Abhishek Katakwar, M.D.a, Ming-Che Hsin, M.D.a,b, Chi-Ming Tai, M.D.a,d, Chih-Kun Huang, M.D.a,b,* a
Bariatric and Metabolic International Surgery Center, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan Division of General Surgery, Department of Surgery, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan c Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan d Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan Received February 6, 2016; accepted February 18, 2016
b
Abstract
Background: Laparoscopic adjustable gastric banded plication (LAGBP) is a novel bariatric procedure, and little is known about its potential complications. Objectives: Herein, we report on complications of LAGBP and discuss the clinical features and diagnostic and therapeutic strategies in such situations, with emphasis on gastric fold herniation (GFH). Setting: University Hospital. Methods: Prospectively collected data of 223 patients who underwent LAGBP for morbid obesity between August 2009 and December 2014 were retrospectively analyzed. Follow-up at 1 year was 75%. Results: Eight patients (3.5%) required readmission due to major complications, including 1 trocar site hernia, 1 band leak, 1 gastric stenosis, and 5 GFHs. GFHs occurred mostly in the first postoperative month (4/5, 80%) and at the fundus (5/5, 100%); 4 GFHs occurred in the initial 70 patients. Seven laparoscopic reoperations were required for managing GFH. The gastric band was removed in 3 patients (of 5; 60%). Two patients developed residual intra-abdominal abscess and were treated successfully by image-guided drainage. In March 2012, we reversed the order of our surgical techniques for the subsequent 153 patients and performed greater curvature plication first, followed by band placement. Only one GFH occurred after this change in surgical order (1/153 versus 4/70; P o .05). Conclusions: High clinical suspicion assisted by radiological investigations and early surgical intervention is the key for managing GFH after LAGBP. Though GFH complications were rare, we significantly reduced its occurrence by altering the surgical order in LAGBP to plication followed by banding. (Surg Obes Relat Dis ]]]];]:]]]–]]].) r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Gastric fold herniation; Laparoscopic adjustable gastric banding; Laparoscopic adjustable gastric banded plication; Laparoscopic greater curvature plication
Funding: There is no external source of funding. * Correspondence: Chih-Kun Huang, M.D., No. 1, Yi-Da Road, Jiao-Su Village, Yan-Chao Distinct, Kaohsiung City, 824, Taiwan. E-mail: [email protected]
Obesity is a global epidemic usually associated with significant co-morbidities such as diabetes mellitus, hyperlipidemia, or hypertension [1]. Surgical intervention has been an effective solution for morbid obesity, achieving sustainable weight loss [2]. At present, laparoscopic Roux-en-Y
http://dx.doi.org/10.1016/j.soard.2016.02.017 1550-7289/r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
P.-C. Chang et al. / Surgery for Obesity and Related Diseases ] (]]]]) ]]]–]]]
gastric bypass, adjustable gastric banding (AGB), and sleeve gastrectomy are widely accepted bariatric procedures for morbid obesity and lead to moderate excess weight loss (EWL) [3–5]. Although Roux-en-Y gastric bypass and sleeve gastrectomy could achieve more EWL than AGB, these 2 procedures have several shortcomings, such as micronutrient deficiency after Roux-en-Y gastric bypass and irreversible anatomy after sleeve gastrectomy [6–8]. By maintaining the gastrointestinal continuity and being a relatively reversible procedure, laparoscopic adjustable gastric banded plication (LAGBP) compensates for the lacunae of current surgical options [9–12]. We added greater curvature plication for insufficient weight loss after initial laparoscopic adjustable gastric banding, and this was the prototype of LAGBP in our experience [10]. LAGBP can achieve moderate weight loss from the initial greater curvature plication, and further weight loss can be attained by adjusting the band during follow-up period [9,10,12]. Moreover, LAGBP has a comparable weight loss effect with sleeve gastrectomy and can achieve 54.9%–56.3% and 65.8%–66.9% EWL at 12 and 24 postoperative months, respectively [12,13]. However, very little has been written about complications after LAGBP and their management [12–15]. Complications after its constituent procedures, laparoscopic greater curvature plication (LGCP) and laparoscopic adjustable gastric banding (LAGB), include band erosion, slippage, pouch enlargement, port breakage, gastrointestinal bleed, or gastric obstruction [4,5,16–21], and may also pertain to LAGBP. Of these complications, a rare but serious complication is gastric fold herniation (GFH; Fig. 1). Here, we describe our experience in treating this complication after LAGBP. We reviewed its presenting symptoms, diagnostic investigations, and possible strategies
to minimize this complication in the learning curve stage of LAGBP. Methods A retrospective review was performed on our prospectively collected database of patients undergoing LAGBP for morbid obesity at a single Asian institute from August 2009 to December 2014. Institutional review board approval (EMRP32101 N[RI]) was obtained to review the data and report the analysis. All procedures were performed by a single bariatric surgeon. Inclusion criteria followed the guidelines for bariatric surgeries, and included body mass index (BMI) exceeding 37 kg/m2 or a BMI greater than 32 kg/m2 with multiple co-morbidities. The patients excluded were those with malignancies, major psychiatric disorders, previous gastric surgery, liver cirrhosis with portal hypertension, and severe gastroesophageal reflux disease. A total of 223 consecutive patients, including 74 men and 149 women with an average age of 31.2 years (range 18–60), were enrolled in the study. The mean preoperative BMI was 38.3 kg/m2 (range 32.1–63.7). Patient follow-up at 1 year was 75%, with a mean follow-up of 20.7 ⫾ 15.2 months (range 2–67). Surgical procedures in LAGBP and their standardization Our surgical techniques were described previously in full detail [9,11,12]. Briefly, surgery for the initial 70 patients included placement of an adjustable gastric band using the standard pars flaccida technique [10], dissection of the greater omentum from antrum (3 cm from pylorus) to angle of His, calibration with a 38 Fr. orogastric tube, 2-layer
Fig. 1. (A) Technically-correct LAGBP. (B) Gastric fold herniation after LAGBP. LAGBP ¼ laparoscopic adjustable gastric banded plication.
Gastric Fold Herniation / Surgery for Obesity and Related Diseases ] (]]]]) ]]]–]]]
plication (from angle of His to antrum) with first layer by interrupted 2-0 Ethibond Excel sutures (Ethicon, StStevens-Woluwe, Belgium) and second layer by continuous 2-0 Ethibond Excel sutures (Ethicon), extension of the silicon tube of the adjustable gastric band through the umbilicus, and placement of the access port in the subcutaneous space. Cefazolin (1 mg every 8 hours), pantoprazole (40 mg every 24 hours), and dexamethasone (5 mg every 8 hours) were intravenously administered to the patients for 1–2 days postoperatively. Moreover, we added the serotonin receptor antagonist Navoban (Sandoz Pharma Ltd., Basel, Switzerland), to alleviate obvious nausea and/or vomiting in the immediate postoperative period. A liquid diet was prescribed, and the patients were discharged promptly if they did not complain of vomiting or any other problem. During follow-up, band adjustments were made only when a patient’s weight loss had reached a plateau. In March 2012, we modified our surgical techniques and switched from a “banding-first” method to a “plication-first” technique to facilitate complete fundus plication for the subsequent 153 patients. Secondly, we replaced the second layer plication from 2-O Ethibond Excel to continuous 2-O Prolene sutures (Ethicon) to tighten the outer layer of greater curvature plication. The following variables were analyzed retrospectively: predominant symptoms, tests done to reach the diagnosis, time interval between the initial operation and the episode of GFH, routes of approach (laparoscopy or laparotomy), surgical outcomes, perioperative morbidity and mortality, complications, length of stay, postoperative management, and follow-up. Results The mean excess weight loss of our patients undergoing LAGBP at 12 and 24 months after surgery was 56.5% and 61.6%, respectively. Eight of the 223 patients (3.5%) had postoperative complications requiring readmission, including 1 trocar site hernia, 1 band leak, 1 gastric stenosis, and
3
5 GFHs. The 5 patients with GFHs (5/223, 2.2%; Tables 1 and 2) were all females with a median age of 27 years (range 19–39) and median BMI of 42.4 kg/m2 (range 34.6– 48.9; Table 1). The median interval between LAGBP and the presentation of symptoms was 7 days (range 5–319). The common presenting symptoms were unrelenting abdominal pain and vomiting (80%; Table 2). Fever (2/5, 40%) was suggestive of a coexisting intra-abdominal infection with concomitant gastric necrosis or perforation. These patients underwent radiological studies, such as upright plain abdomen films or abdominal computed tomography (CT), before being considered for surgical reexploration (Table 2). A “positive” upright plain abdominal x-ray film usually found a typical “gastric bubble” below the left hemidiaphragm (Fig. 2). For those with GFHs after LAGBP, the abdominal CT scan found a “diverticulumlike” lesion protruding from the plicated stomach (Fig. 3). The positive rate of abdominal CT and upright plain film were 100% (4/4) and 75% (3/4), respectively. All GFHs were located at the fundus and most occurred within the first month after the procedure (4/5, 80%). All GFHs required laparoscopic exploration and a total of 7 laparoscopic procedures were carried out. No surgical mortality occurred during the follow-up and most patients (4/5, 80%) were discharged within 2 weeks after the surgical treatment for GFHs. However, one patient (No. 5) had a protracted hospital stay (30 d) due to a residual intra-abdominal abscess. In this patient, we initially tried to preserve the adjustable gastric band despite the presence of exudate and fibrin formation within the peritoneal cavity. Resection of necrotic gastric fold with linear stapler (Covidien, North Haven, CT) was conducted; however, due to intractable intra-abdominal infection, this patient required CT-guided drainage and subsequent removal of the adjustable gastric band by laparoscopy. Simple deplication was conducted for 1 patient (No. 1) with an acceptable weight loss of 29 kg (48% of EWL) 319 days after initial LAGBP. The patient had further weight loss by gastric band adjustment during the follow-up period. Immediate repair of the perforated
Table 1 Demographic data of 5 patients with gastric fold herniation after LAGBP Patient
1
2
3
4
5
Age (yr) Sex BMI (kg/m2) Co-morbidity
19 F 39.7 Hyperuricemia Asthma Yes No 71 1 319
32 F 34.6 Hyperlipidemia NASH Asthma Yes No 83 0 15
39 F 43.6 NASH
Banding-first procedure Plication-first procedure Operative time (min) Frequency of band adjustment Interval between appearance of symptom and LAGBP (d)
24 F 42.4 Hyperuricemia NASH Hyperlipidemia Yes No 130 0 7
27 F 48.9 GERD NASH Hyperuricemia No Yes 80 0 5
Yes No 78 0 7
LAGBP ¼ laparoscopic adjustable gastric banded plication; F ¼ female; BMI ¼ body mass index; NASH ¼ nonalcoholic steatohepatitis; GERD ¼ gastroesophageal reflux disease.
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P.-C. Chang et al. / Surgery for Obesity and Related Diseases ] (]]]]) ]]]–]]]
Table 2 Clinical characteristics and treatment of 5 patients with gastric fold herniation after LAGBP Patient No.
1
2
3
4
5
Symptoms
Vomiting
Fever Abdominal pain
Abdominal pain Vomiting
Abdominal pain Vomiting Fever
Positive finding on plain film Positive finding on abdomen CT Location of GFH Associated intraoperative finding
þ þ F Obstruction Congestion 1 Deplication
N/A þ F Gangrene IAI 1 Resection and band removal
– þ F Perforation IAI 2 1st: Deplication and repair 2nd: Band removal
Vomiting Dysphagia Abdominal pain þ N/A F Obstruction Gangrene 1 Resection
Number of laparoscopy procedures Type of laparoscopic intervention
CT-guided drainage for residual IAI Hospital stay after initial laparoscopic surgery (days)
– 4
þ 14
– 6
– 14
þ þ F Gangrene IAI 2 1st: Resection 2nd: Band removal þ 30
LAGBP ¼ laparoscopic adjustable gastric banded plication; þ ¼ yes; N/A ¼ not available; – ¼ no; CT ¼ computed tomography; GFH ¼ gastric fold herniation; F ¼ fundus; IAI ¼ intra-abdominal infection.
gastric fold after deplication was conducted for only one patient (No. 3). Resection of necrotic herniated gastric fold with linear stapler was performed for the remaining 3 patients (Nos. 2, 4, and 5). The staple line was reinforced by oversewing with 2-O Prolene (Ethicon, Somerville, NJ), as the stomach tissue was quite swollen due to the inflammation. The adjustable gastric band was removed in 3 patients (of 5 patients with GFH, 60%) due to coexisting intraabdominal infection. In these patients (Nos. 2, 3, and 5), the adjustable gastric band removal was initially deferred as we expected to salvage the band by controlling the intraabdominal infection by other means. This attempt failed,
however, and we had to remove the band from patients 3 and 5 due to persistent infection and uncontrollable sepsis. For those patients who had to undergo adjustable band removal, we arranged for elective sleeve gastrectomy after 2 to 3 months. For patient 2, CT-guided drainage of intra-abdominal abscess was tried initially and infection could not be controlled successfully; hence, laparoscopic resection of gangrenous herniated gastric fold and band removal was performed. Discussion Though LAGBP is a relatively new procedure and is still under investigation, it has an acceptable weight loss
Fig. 2. Abdominal films of 2 patients who had undergone laparoscopic adjustable gastric banded plication. (A) The normal, upright plain abdominal film after laparoscopic adjustable gastric banded plication did not show distended gastric bubble under left hemidiaphragm. (B) The upright, plain film revealed the stomach bubble with fluid level under the left hemidiaphragm (arrow), indicative of gastric fold herniation.
Gastric Fold Herniation / Surgery for Obesity and Related Diseases ] (]]]]) ]]]–]]]
comparable to LSG, approaching 70% EWL at 2 years [12]. As the gastrointestinal continuity remains intact, long-term vitamin supplementation may not be required [12,13]. In addition, stomach plication can be reversed in certain conditions [11,17]. Despite these advantages, LAGBP has its shortcomings and associated complications. Besides the additional cost of this combined procedure (LGCP with AGB), no definite consensus exists in the management of complications from LAGBP. Complications might arise from the laparoscopic procedure itself, either during adjustable gastric band placement or during greater curvature plication. Ours is the largest series of LAGBPs published to date. Eight patients (3.5%) needed readmission for postoperative complications such as trocar site hernia, gastric band leak, gastric stenosis, or GFHs. Among these, GFH is the most dreaded complication due to its severity and rarity; its symptoms include unrelenting pain or vomiting, mimicking bowel herniation and/or strangulation [14]. In patients with concomitant fever, the possibility of a coexisting intraabdominal infectious process, such as gastric necrosis or perforation, should be ruled out. This usually occurs in the early postoperative period, mostly within the first month (4/5, 80%). Currently, the available literature on the appropriate radiological studies for GCP or LAGBP is scarce [14,17]. Patients who presented with intractable abdominal pain or vomiting after LAGBP required urgent radiological studies, such as upright plain films or abdominal CT, to exclude the possible existence of GFH. In the upright abdominal plain film, GFH can be diagnosed by the presence of a gastric bubble (Fig. 2). The abdominal CT, which is the most sensitive study for acute abdominal emergencies, typically shows bulging of the herniated segment from the plicated stomach (Fig. 3). In our series, the positive rate of abdominal CT for detecting GFHs approached 100% (4/4).
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GFHs usually warrant urgent reoperation once diagnosed. If left untreated, the congested stomach would eventually progress to full-thickness ischemia, necrosis, and even perforation. As for the surgical options, all of them could be managed laparoscopically in our series, and the algorithm was proposed based on our own experience (Fig. 4). The condition of herniated gastric folds dictates the management for GFHs. For patients with significant weight loss while diagnosed with gastric congestion intraoperatively, laparoscopic deplication could relieve the intractable symptoms and subsequent weight loss could be achieved via band adjustments only. The patient with inadequate weight loss and congested gastric fold received deplication followed by replication laparoscopically. Patients with gastric necrosis experience the distinct levels of necrosis and coexisting intra-abdominal inflammation, which determine the subsequent management. A small perforation detected at an initial stage usually is resolved by direct deplication, with repair and preservation of the adjustable gastric band to augment weight loss. The patients with full-layer necrosis may require resection via linear staplers with concomitant oversewing. However, removal of the adjustable gastric band should be performed without hesitation for those GFHs with exudate or fibrin formation during laparoscopic exploration. This will prevent intra-abdominal abscess requiring subsequent drainage procedures. In an extensive review of the published literature regarding GCP for morbid obesity, only 4 articles described the rare existence of GFHs [18–21]. GFH itself is a devastating complication after GCP, with incidence varying from .1 to 7.6% [18–21]. Many etiologies might contribute to the pathogenesis of GFHs, including suture disruption or loosening of the plication during surgical manipulations. In response to the relatively higher incidence of GFH in our series (5/223, 2.2%), we surmised
Fig. 3. Abdominal computed tomography, (A) axial and (B) coronal views, of reported gastric fold hernia after LAGBP. One “outpouching” gastric fold (arrow) arose from the plicated stomach (asterisk) with air-fluid content. The adjustable gastric band was marked with arrowhead in situ. LAGBP ¼ laparoscopic adjustable gastric banded plication.
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P.-C. Chang et al. / Surgery for Obesity and Related Diseases ] (]]]]) ]]]–]]]
Fig. 4. Algorithm for treatment of gastric fold herniation after LAGBP. EWL ¼ excess weight loss; LAGBP ¼ laparoscopic adjustable gastric banded plication.
that the “banding-first” method might be hindering adequate and complete plication at the fundus. This, coupled with sudden rise in intragastric pressure (as in coughing/retching) could lead to GFH. This could also be explained by the comparatively higher occurrence of GFHs in the learning curve stage of LAGBP in our series (4/70; 5.7%). Moreover, a “2-row” plication procedure might predispose to a higher rate of GFH than a “3-row” or other procedure [19,20]. Therefore, we modified our initial surgical technique. Now we place the adjustable gastric band after completing gastric plication to ensure that plication at the fundus is complete. Based on our experience, it would be much safer to place the gastric band via standard pars flaccida technique than pure adjustable gastric banding procedure due to complete dissection of the fat pad surrounding the gastroesophageal junction after detachment of greater omentum from the stomach and greater curvature plication. It would not be too risky to add the gastric band. Also, we changed to polypropylene sutures (Prolene 2-O, Ethicon) for the second-layer plication instead of polyester sutures (Ethibond Excel 2-O, Ethicon) for the former’s smoother texture and stretchable character. This would make the plicated stomach tighter
and ensure that the imbricated gastric folds were compact within the plication chamber, which would make it more resistant to significant increased intragastric pressure and less prone to subsequent herniation thereby. Since this change (March 2012 onwards), only one GFH has occurred (4/70 versus 1/153; P o .05). However, longer follow-up time is necessary to confirm this finding. In addition, we prescribe aggressive antiemetics and serotonin receptor antagonists pre- and postoperatively, so that patients remain comfortable and are free of retching. Conclusion In conclusion, LAGBP is a well-tolerated, nonresectional bariatric procedure with acceptable results. A high index of clinical suspicion followed by radiological investigations with early surgical intervention is the key to successful treatment of GFHs. Our technical modifications have reduced the incidence of this complication and made it more tolerable. Since the potential risk/morbidity of GFH or gastric necrosis is very low (2.2% in our series), LAGBP is not inferior to sleeve gastrectomy.
Gastric Fold Herniation / Surgery for Obesity and Related Diseases ] (]]]]) ]]]–]]]
Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Brixner DI, Bron M, Bellows BK, et al. Evaluation of cardiovascular risk factors, events, and costs across four BMI categories. Obesity (Silver Spring) 2013;21(6):1284–92. [2] Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and costeffectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess 2009;13 (41):1–190, 215–357. [3] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23(4):427–36. [4] Carlin AM, Zeni TM, English WJ, et al. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg 2013;257(5):791–7. [5] Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012. JAMA Surg 2014;149 (3):275–87. [6] Gong K, Gagner M, Pomp A, Almahmeed T, Bardaro SJ. Micronutrient deficiencies after laparoscopic gastric bypass: recommendations. Obes Surg 2008;18(9):1062–6. [7] Gehrer S, Kern B, Peters T, Christoffel-Courtin C, Peterli R. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB)-a prospective study. Obes Surg 2010;20(4):447–53. [8] Damms-Machado A, Friedrich A, Kramer KM, et al. Pre- and postoperative nutritional deficiencies in obese patients undergoing laparoscopic sleeve gastrectomy. Obes Surg 2012;22(6):881–9. [9] Huang CK, Lo CH, Shabbir A, Tai CM. Novel bariatric technology: laparoscopic adjustable gastric banded plication: technique and preliminary results. Surg Obes Relat Dis 2012;8(1):41–5.
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[10] Huang CK, Asim S, Lo CH. Augmenting weight loss after laparoscopic adjustable gastric banding by laparoscopic gastric plication. Surg Obes Relat Dis 2011;7(2):235–6. [11] Goel R, Chang PC, Huang CK. Reversal of gastric plication after laparoscopic adjustable gastric banded plication. Surg Obes Relat Dis 2013;9(1):e14–5. [12] Huang CK, Chhabra N, Goel R, Hung CM, Chang PC, Chen YS. Laparoscopic adjustable gastric banded plication: a case-matched comparative study with laparoscopic sleeve gastrectomy. Obes Surg 2013;23(8):1319–23. [13] Pattanshetti S, Tai CM, Yen YC, Lin HY, Chi SC, Huang CK. Laparoscopic adjustable gastric banded plication: evolution of procedure and 2-year results. Obes Surg 2013;23(11):1934–8. [14] Tai CM, Chang PC, Huang CK. An unusual cause of vomiting after bariatric surgery. Gastroenterology 2013;144(5):e1–2. [15] Hii MW, Clarke NE, Hopkins GH. Gastrogastric herniation: an unusual complication following greater curve plication for the treatment of morbid obesity. Ann R Coll Surg Engl 2012;94(2):e76–8. [16] Miller KA. Evolution of gastric band implantation and port fixation techniques. Surg Obes Relat Dis 2008;4(Suppl 3):S22–30. [17] Roesel DM, Remer EM, Brethauer SA, Schauer PR. Imaging evaluation of laparoscopic greater curvature plication: preliminary observations. AJR Am J Roentgenol 2013;201(2):W262–70. [18] Pujol Gebelli J, García Ruiz de Gordejuela A, Casajoana Badía A, Secanella Medayo L, Vicens Morton A, Masdevall Noguera C. Laparoscopic gastric plication: a new surgery for the treatment of morbid obesity. Cir Esp 2011;89(6):356–61. [19] Skrekas G, Antiochos K, Stafyla VK. Laparoscopic gastric greater curvature plication: results and complications in a series of 135 patients. Obes Surg 2011;21(11):1657–63. [20] Talebpour M, Motamedi SM, Talebpour A, Vahidi H. Twelve year experience of laparoscopic gastric plication in morbid obesity: development of the technique and patient outcomes. Ann Surg Innov Res 2012;6(1):7. [21] Atlas H, Yazbek T, Garneau PY, Safa N, Denis R. Is there a future for laparoscopic gastric greater curvature plication (LGGCP)? A review of 44 patients. Obes Surg 2013;23(9):1397–403.
Original article
Management of gastric fold herniation after laparoscopic adjustable gastric banded plication: a single-center experience Po-Chih Chang, M.D.a,b,c, Anshuman Dev, M.D.a, Abhishek Katakwar, M.D.a, Ming-Che Hsin, M.D.a,b, Chi-Ming Tai, M.D.a,d, Chih-Kun Huang, M.D.a,b,* a
Bariatric and Metabolic International Surgery Center, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan Division of General Surgery, Department of Surgery, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan c Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan d Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan Received February 6, 2016; accepted February 18, 2016
b
Abstract
Background: Laparoscopic adjustable gastric banded plication (LAGBP) is a novel bariatric procedure, and little is known about its potential complications. Objectives: Herein, we report on complications of LAGBP and discuss the clinical features and diagnostic and therapeutic strategies in such situations, with emphasis on gastric fold herniation (GFH). Setting: University Hospital. Methods: Prospectively collected data of 223 patients who underwent LAGBP for morbid obesity between August 2009 and December 2014 were retrospectively analyzed. Follow-up at 1 year was 75%. Results: Eight patients (3.5%) required readmission due to major complications, including 1 trocar site hernia, 1 band leak, 1 gastric stenosis, and 5 GFHs. GFHs occurred mostly in the first postoperative month (4/5, 80%) and at the fundus (5/5, 100%); 4 GFHs occurred in the initial 70 patients. Seven laparoscopic reoperations were required for managing GFH. The gastric band was removed in 3 patients (of 5; 60%). Two patients developed residual intra-abdominal abscess and were treated successfully by image-guided drainage. In March 2012, we reversed the order of our surgical techniques for the subsequent 153 patients and performed greater curvature plication first, followed by band placement. Only one GFH occurred after this change in surgical order (1/153 versus 4/70; P o .05). Conclusions: High clinical suspicion assisted by radiological investigations and early surgical intervention is the key for managing GFH after LAGBP. Though GFH complications were rare, we significantly reduced its occurrence by altering the surgical order in LAGBP to plication followed by banding. (Surg Obes Relat Dis ]]]];]:]]]–]]].) r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Gastric fold herniation; Laparoscopic adjustable gastric banding; Laparoscopic adjustable gastric banded plication; Laparoscopic greater curvature plication
Funding: There is no external source of funding. * Correspondence: Chih-Kun Huang, M.D., No. 1, Yi-Da Road, Jiao-Su Village, Yan-Chao Distinct, Kaohsiung City, 824, Taiwan. E-mail: [email protected]
Obesity is a global epidemic usually associated with significant co-morbidities such as diabetes mellitus, hyperlipidemia, or hypertension [1]. Surgical intervention has been an effective solution for morbid obesity, achieving sustainable weight loss [2]. At present, laparoscopic Roux-en-Y
http://dx.doi.org/10.1016/j.soard.2016.02.017 1550-7289/r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
P.-C. Chang et al. / Surgery for Obesity and Related Diseases ] (]]]]) ]]]–]]]
gastric bypass, adjustable gastric banding (AGB), and sleeve gastrectomy are widely accepted bariatric procedures for morbid obesity and lead to moderate excess weight loss (EWL) [3–5]. Although Roux-en-Y gastric bypass and sleeve gastrectomy could achieve more EWL than AGB, these 2 procedures have several shortcomings, such as micronutrient deficiency after Roux-en-Y gastric bypass and irreversible anatomy after sleeve gastrectomy [6–8]. By maintaining the gastrointestinal continuity and being a relatively reversible procedure, laparoscopic adjustable gastric banded plication (LAGBP) compensates for the lacunae of current surgical options [9–12]. We added greater curvature plication for insufficient weight loss after initial laparoscopic adjustable gastric banding, and this was the prototype of LAGBP in our experience [10]. LAGBP can achieve moderate weight loss from the initial greater curvature plication, and further weight loss can be attained by adjusting the band during follow-up period [9,10,12]. Moreover, LAGBP has a comparable weight loss effect with sleeve gastrectomy and can achieve 54.9%–56.3% and 65.8%–66.9% EWL at 12 and 24 postoperative months, respectively [12,13]. However, very little has been written about complications after LAGBP and their management [12–15]. Complications after its constituent procedures, laparoscopic greater curvature plication (LGCP) and laparoscopic adjustable gastric banding (LAGB), include band erosion, slippage, pouch enlargement, port breakage, gastrointestinal bleed, or gastric obstruction [4,5,16–21], and may also pertain to LAGBP. Of these complications, a rare but serious complication is gastric fold herniation (GFH; Fig. 1). Here, we describe our experience in treating this complication after LAGBP. We reviewed its presenting symptoms, diagnostic investigations, and possible strategies
to minimize this complication in the learning curve stage of LAGBP. Methods A retrospective review was performed on our prospectively collected database of patients undergoing LAGBP for morbid obesity at a single Asian institute from August 2009 to December 2014. Institutional review board approval (EMRP32101 N[RI]) was obtained to review the data and report the analysis. All procedures were performed by a single bariatric surgeon. Inclusion criteria followed the guidelines for bariatric surgeries, and included body mass index (BMI) exceeding 37 kg/m2 or a BMI greater than 32 kg/m2 with multiple co-morbidities. The patients excluded were those with malignancies, major psychiatric disorders, previous gastric surgery, liver cirrhosis with portal hypertension, and severe gastroesophageal reflux disease. A total of 223 consecutive patients, including 74 men and 149 women with an average age of 31.2 years (range 18–60), were enrolled in the study. The mean preoperative BMI was 38.3 kg/m2 (range 32.1–63.7). Patient follow-up at 1 year was 75%, with a mean follow-up of 20.7 ⫾ 15.2 months (range 2–67). Surgical procedures in LAGBP and their standardization Our surgical techniques were described previously in full detail [9,11,12]. Briefly, surgery for the initial 70 patients included placement of an adjustable gastric band using the standard pars flaccida technique [10], dissection of the greater omentum from antrum (3 cm from pylorus) to angle of His, calibration with a 38 Fr. orogastric tube, 2-layer
Fig. 1. (A) Technically-correct LAGBP. (B) Gastric fold herniation after LAGBP. LAGBP ¼ laparoscopic adjustable gastric banded plication.
Gastric Fold Herniation / Surgery for Obesity and Related Diseases ] (]]]]) ]]]–]]]
plication (from angle of His to antrum) with first layer by interrupted 2-0 Ethibond Excel sutures (Ethicon, StStevens-Woluwe, Belgium) and second layer by continuous 2-0 Ethibond Excel sutures (Ethicon), extension of the silicon tube of the adjustable gastric band through the umbilicus, and placement of the access port in the subcutaneous space. Cefazolin (1 mg every 8 hours), pantoprazole (40 mg every 24 hours), and dexamethasone (5 mg every 8 hours) were intravenously administered to the patients for 1–2 days postoperatively. Moreover, we added the serotonin receptor antagonist Navoban (Sandoz Pharma Ltd., Basel, Switzerland), to alleviate obvious nausea and/or vomiting in the immediate postoperative period. A liquid diet was prescribed, and the patients were discharged promptly if they did not complain of vomiting or any other problem. During follow-up, band adjustments were made only when a patient’s weight loss had reached a plateau. In March 2012, we modified our surgical techniques and switched from a “banding-first” method to a “plication-first” technique to facilitate complete fundus plication for the subsequent 153 patients. Secondly, we replaced the second layer plication from 2-O Ethibond Excel to continuous 2-O Prolene sutures (Ethicon) to tighten the outer layer of greater curvature plication. The following variables were analyzed retrospectively: predominant symptoms, tests done to reach the diagnosis, time interval between the initial operation and the episode of GFH, routes of approach (laparoscopy or laparotomy), surgical outcomes, perioperative morbidity and mortality, complications, length of stay, postoperative management, and follow-up. Results The mean excess weight loss of our patients undergoing LAGBP at 12 and 24 months after surgery was 56.5% and 61.6%, respectively. Eight of the 223 patients (3.5%) had postoperative complications requiring readmission, including 1 trocar site hernia, 1 band leak, 1 gastric stenosis, and
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5 GFHs. The 5 patients with GFHs (5/223, 2.2%; Tables 1 and 2) were all females with a median age of 27 years (range 19–39) and median BMI of 42.4 kg/m2 (range 34.6– 48.9; Table 1). The median interval between LAGBP and the presentation of symptoms was 7 days (range 5–319). The common presenting symptoms were unrelenting abdominal pain and vomiting (80%; Table 2). Fever (2/5, 40%) was suggestive of a coexisting intra-abdominal infection with concomitant gastric necrosis or perforation. These patients underwent radiological studies, such as upright plain abdomen films or abdominal computed tomography (CT), before being considered for surgical reexploration (Table 2). A “positive” upright plain abdominal x-ray film usually found a typical “gastric bubble” below the left hemidiaphragm (Fig. 2). For those with GFHs after LAGBP, the abdominal CT scan found a “diverticulumlike” lesion protruding from the plicated stomach (Fig. 3). The positive rate of abdominal CT and upright plain film were 100% (4/4) and 75% (3/4), respectively. All GFHs were located at the fundus and most occurred within the first month after the procedure (4/5, 80%). All GFHs required laparoscopic exploration and a total of 7 laparoscopic procedures were carried out. No surgical mortality occurred during the follow-up and most patients (4/5, 80%) were discharged within 2 weeks after the surgical treatment for GFHs. However, one patient (No. 5) had a protracted hospital stay (30 d) due to a residual intra-abdominal abscess. In this patient, we initially tried to preserve the adjustable gastric band despite the presence of exudate and fibrin formation within the peritoneal cavity. Resection of necrotic gastric fold with linear stapler (Covidien, North Haven, CT) was conducted; however, due to intractable intra-abdominal infection, this patient required CT-guided drainage and subsequent removal of the adjustable gastric band by laparoscopy. Simple deplication was conducted for 1 patient (No. 1) with an acceptable weight loss of 29 kg (48% of EWL) 319 days after initial LAGBP. The patient had further weight loss by gastric band adjustment during the follow-up period. Immediate repair of the perforated
Table 1 Demographic data of 5 patients with gastric fold herniation after LAGBP Patient
1
2
3
4
5
Age (yr) Sex BMI (kg/m2) Co-morbidity
19 F 39.7 Hyperuricemia Asthma Yes No 71 1 319
32 F 34.6 Hyperlipidemia NASH Asthma Yes No 83 0 15
39 F 43.6 NASH
Banding-first procedure Plication-first procedure Operative time (min) Frequency of band adjustment Interval between appearance of symptom and LAGBP (d)
24 F 42.4 Hyperuricemia NASH Hyperlipidemia Yes No 130 0 7
27 F 48.9 GERD NASH Hyperuricemia No Yes 80 0 5
Yes No 78 0 7
LAGBP ¼ laparoscopic adjustable gastric banded plication; F ¼ female; BMI ¼ body mass index; NASH ¼ nonalcoholic steatohepatitis; GERD ¼ gastroesophageal reflux disease.
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Table 2 Clinical characteristics and treatment of 5 patients with gastric fold herniation after LAGBP Patient No.
1
2
3
4
5
Symptoms
Vomiting
Fever Abdominal pain
Abdominal pain Vomiting
Abdominal pain Vomiting Fever
Positive finding on plain film Positive finding on abdomen CT Location of GFH Associated intraoperative finding
þ þ F Obstruction Congestion 1 Deplication
N/A þ F Gangrene IAI 1 Resection and band removal
– þ F Perforation IAI 2 1st: Deplication and repair 2nd: Band removal
Vomiting Dysphagia Abdominal pain þ N/A F Obstruction Gangrene 1 Resection
Number of laparoscopy procedures Type of laparoscopic intervention
CT-guided drainage for residual IAI Hospital stay after initial laparoscopic surgery (days)
– 4
þ 14
– 6
– 14
þ þ F Gangrene IAI 2 1st: Resection 2nd: Band removal þ 30
LAGBP ¼ laparoscopic adjustable gastric banded plication; þ ¼ yes; N/A ¼ not available; – ¼ no; CT ¼ computed tomography; GFH ¼ gastric fold herniation; F ¼ fundus; IAI ¼ intra-abdominal infection.
gastric fold after deplication was conducted for only one patient (No. 3). Resection of necrotic herniated gastric fold with linear stapler was performed for the remaining 3 patients (Nos. 2, 4, and 5). The staple line was reinforced by oversewing with 2-O Prolene (Ethicon, Somerville, NJ), as the stomach tissue was quite swollen due to the inflammation. The adjustable gastric band was removed in 3 patients (of 5 patients with GFH, 60%) due to coexisting intraabdominal infection. In these patients (Nos. 2, 3, and 5), the adjustable gastric band removal was initially deferred as we expected to salvage the band by controlling the intraabdominal infection by other means. This attempt failed,
however, and we had to remove the band from patients 3 and 5 due to persistent infection and uncontrollable sepsis. For those patients who had to undergo adjustable band removal, we arranged for elective sleeve gastrectomy after 2 to 3 months. For patient 2, CT-guided drainage of intra-abdominal abscess was tried initially and infection could not be controlled successfully; hence, laparoscopic resection of gangrenous herniated gastric fold and band removal was performed. Discussion Though LAGBP is a relatively new procedure and is still under investigation, it has an acceptable weight loss
Fig. 2. Abdominal films of 2 patients who had undergone laparoscopic adjustable gastric banded plication. (A) The normal, upright plain abdominal film after laparoscopic adjustable gastric banded plication did not show distended gastric bubble under left hemidiaphragm. (B) The upright, plain film revealed the stomach bubble with fluid level under the left hemidiaphragm (arrow), indicative of gastric fold herniation.
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comparable to LSG, approaching 70% EWL at 2 years [12]. As the gastrointestinal continuity remains intact, long-term vitamin supplementation may not be required [12,13]. In addition, stomach plication can be reversed in certain conditions [11,17]. Despite these advantages, LAGBP has its shortcomings and associated complications. Besides the additional cost of this combined procedure (LGCP with AGB), no definite consensus exists in the management of complications from LAGBP. Complications might arise from the laparoscopic procedure itself, either during adjustable gastric band placement or during greater curvature plication. Ours is the largest series of LAGBPs published to date. Eight patients (3.5%) needed readmission for postoperative complications such as trocar site hernia, gastric band leak, gastric stenosis, or GFHs. Among these, GFH is the most dreaded complication due to its severity and rarity; its symptoms include unrelenting pain or vomiting, mimicking bowel herniation and/or strangulation [14]. In patients with concomitant fever, the possibility of a coexisting intraabdominal infectious process, such as gastric necrosis or perforation, should be ruled out. This usually occurs in the early postoperative period, mostly within the first month (4/5, 80%). Currently, the available literature on the appropriate radiological studies for GCP or LAGBP is scarce [14,17]. Patients who presented with intractable abdominal pain or vomiting after LAGBP required urgent radiological studies, such as upright plain films or abdominal CT, to exclude the possible existence of GFH. In the upright abdominal plain film, GFH can be diagnosed by the presence of a gastric bubble (Fig. 2). The abdominal CT, which is the most sensitive study for acute abdominal emergencies, typically shows bulging of the herniated segment from the plicated stomach (Fig. 3). In our series, the positive rate of abdominal CT for detecting GFHs approached 100% (4/4).
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GFHs usually warrant urgent reoperation once diagnosed. If left untreated, the congested stomach would eventually progress to full-thickness ischemia, necrosis, and even perforation. As for the surgical options, all of them could be managed laparoscopically in our series, and the algorithm was proposed based on our own experience (Fig. 4). The condition of herniated gastric folds dictates the management for GFHs. For patients with significant weight loss while diagnosed with gastric congestion intraoperatively, laparoscopic deplication could relieve the intractable symptoms and subsequent weight loss could be achieved via band adjustments only. The patient with inadequate weight loss and congested gastric fold received deplication followed by replication laparoscopically. Patients with gastric necrosis experience the distinct levels of necrosis and coexisting intra-abdominal inflammation, which determine the subsequent management. A small perforation detected at an initial stage usually is resolved by direct deplication, with repair and preservation of the adjustable gastric band to augment weight loss. The patients with full-layer necrosis may require resection via linear staplers with concomitant oversewing. However, removal of the adjustable gastric band should be performed without hesitation for those GFHs with exudate or fibrin formation during laparoscopic exploration. This will prevent intra-abdominal abscess requiring subsequent drainage procedures. In an extensive review of the published literature regarding GCP for morbid obesity, only 4 articles described the rare existence of GFHs [18–21]. GFH itself is a devastating complication after GCP, with incidence varying from .1 to 7.6% [18–21]. Many etiologies might contribute to the pathogenesis of GFHs, including suture disruption or loosening of the plication during surgical manipulations. In response to the relatively higher incidence of GFH in our series (5/223, 2.2%), we surmised
Fig. 3. Abdominal computed tomography, (A) axial and (B) coronal views, of reported gastric fold hernia after LAGBP. One “outpouching” gastric fold (arrow) arose from the plicated stomach (asterisk) with air-fluid content. The adjustable gastric band was marked with arrowhead in situ. LAGBP ¼ laparoscopic adjustable gastric banded plication.
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Fig. 4. Algorithm for treatment of gastric fold herniation after LAGBP. EWL ¼ excess weight loss; LAGBP ¼ laparoscopic adjustable gastric banded plication.
that the “banding-first” method might be hindering adequate and complete plication at the fundus. This, coupled with sudden rise in intragastric pressure (as in coughing/retching) could lead to GFH. This could also be explained by the comparatively higher occurrence of GFHs in the learning curve stage of LAGBP in our series (4/70; 5.7%). Moreover, a “2-row” plication procedure might predispose to a higher rate of GFH than a “3-row” or other procedure [19,20]. Therefore, we modified our initial surgical technique. Now we place the adjustable gastric band after completing gastric plication to ensure that plication at the fundus is complete. Based on our experience, it would be much safer to place the gastric band via standard pars flaccida technique than pure adjustable gastric banding procedure due to complete dissection of the fat pad surrounding the gastroesophageal junction after detachment of greater omentum from the stomach and greater curvature plication. It would not be too risky to add the gastric band. Also, we changed to polypropylene sutures (Prolene 2-O, Ethicon) for the second-layer plication instead of polyester sutures (Ethibond Excel 2-O, Ethicon) for the former’s smoother texture and stretchable character. This would make the plicated stomach tighter
and ensure that the imbricated gastric folds were compact within the plication chamber, which would make it more resistant to significant increased intragastric pressure and less prone to subsequent herniation thereby. Since this change (March 2012 onwards), only one GFH has occurred (4/70 versus 1/153; P o .05). However, longer follow-up time is necessary to confirm this finding. In addition, we prescribe aggressive antiemetics and serotonin receptor antagonists pre- and postoperatively, so that patients remain comfortable and are free of retching. Conclusion In conclusion, LAGBP is a well-tolerated, nonresectional bariatric procedure with acceptable results. A high index of clinical suspicion followed by radiological investigations with early surgical intervention is the key to successful treatment of GFHs. Our technical modifications have reduced the incidence of this complication and made it more tolerable. Since the potential risk/morbidity of GFH or gastric necrosis is very low (2.2% in our series), LAGBP is not inferior to sleeve gastrectomy.
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Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Brixner DI, Bron M, Bellows BK, et al. Evaluation of cardiovascular risk factors, events, and costs across four BMI categories. Obesity (Silver Spring) 2013;21(6):1284–92. [2] Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and costeffectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess 2009;13 (41):1–190, 215–357. [3] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23(4):427–36. [4] Carlin AM, Zeni TM, English WJ, et al. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg 2013;257(5):791–7. [5] Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012. JAMA Surg 2014;149 (3):275–87. [6] Gong K, Gagner M, Pomp A, Almahmeed T, Bardaro SJ. Micronutrient deficiencies after laparoscopic gastric bypass: recommendations. Obes Surg 2008;18(9):1062–6. [7] Gehrer S, Kern B, Peters T, Christoffel-Courtin C, Peterli R. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB)-a prospective study. Obes Surg 2010;20(4):447–53. [8] Damms-Machado A, Friedrich A, Kramer KM, et al. Pre- and postoperative nutritional deficiencies in obese patients undergoing laparoscopic sleeve gastrectomy. Obes Surg 2012;22(6):881–9. [9] Huang CK, Lo CH, Shabbir A, Tai CM. Novel bariatric technology: laparoscopic adjustable gastric banded plication: technique and preliminary results. Surg Obes Relat Dis 2012;8(1):41–5.
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[10] Huang CK, Asim S, Lo CH. Augmenting weight loss after laparoscopic adjustable gastric banding by laparoscopic gastric plication. Surg Obes Relat Dis 2011;7(2):235–6. [11] Goel R, Chang PC, Huang CK. Reversal of gastric plication after laparoscopic adjustable gastric banded plication. Surg Obes Relat Dis 2013;9(1):e14–5. [12] Huang CK, Chhabra N, Goel R, Hung CM, Chang PC, Chen YS. Laparoscopic adjustable gastric banded plication: a case-matched comparative study with laparoscopic sleeve gastrectomy. Obes Surg 2013;23(8):1319–23. [13] Pattanshetti S, Tai CM, Yen YC, Lin HY, Chi SC, Huang CK. Laparoscopic adjustable gastric banded plication: evolution of procedure and 2-year results. Obes Surg 2013;23(11):1934–8. [14] Tai CM, Chang PC, Huang CK. An unusual cause of vomiting after bariatric surgery. Gastroenterology 2013;144(5):e1–2. [15] Hii MW, Clarke NE, Hopkins GH. Gastrogastric herniation: an unusual complication following greater curve plication for the treatment of morbid obesity. Ann R Coll Surg Engl 2012;94(2):e76–8. [16] Miller KA. Evolution of gastric band implantation and port fixation techniques. Surg Obes Relat Dis 2008;4(Suppl 3):S22–30. [17] Roesel DM, Remer EM, Brethauer SA, Schauer PR. Imaging evaluation of laparoscopic greater curvature plication: preliminary observations. AJR Am J Roentgenol 2013;201(2):W262–70. [18] Pujol Gebelli J, García Ruiz de Gordejuela A, Casajoana Badía A, Secanella Medayo L, Vicens Morton A, Masdevall Noguera C. Laparoscopic gastric plication: a new surgery for the treatment of morbid obesity. Cir Esp 2011;89(6):356–61. [19] Skrekas G, Antiochos K, Stafyla VK. Laparoscopic gastric greater curvature plication: results and complications in a series of 135 patients. Obes Surg 2011;21(11):1657–63. [20] Talebpour M, Motamedi SM, Talebpour A, Vahidi H. Twelve year experience of laparoscopic gastric plication in morbid obesity: development of the technique and patient outcomes. Ann Surg Innov Res 2012;6(1):7. [21] Atlas H, Yazbek T, Garneau PY, Safa N, Denis R. Is there a future for laparoscopic gastric greater curvature plication (LGGCP)? A review of 44 patients. Obes Surg 2013;23(9):1397–403.