Updated: Sep 5, 2022
Laparoscopic gastric plication (LGP) has a much less durable effect on weight loss with a percentage of excess weight loss (%EWL) of 32% and a weight regain of 58.3%, resulting in a high rate of revisions at the six years, according to researchers from Mansoura University, Mansoura, Egypt. The results were published in the paper, ‘Long-Term Outcomes of Laparoscopic Gastric Plication for Treatment of Morbid Obesity: a Single-Center Experience’, in the journal, Obesity Surgery.
The LGP procedure has increased in popularity because it is more conservative, less invasive, has reversible potency, and has fewer high-risk complications such as leak and bleeding. However, the long-term weight loss outcomes from LCP have been under-reported. The study authors have previously reported 15-month findings from their prospective, consecutive case series of 88 patients with severe obesity who underwent LGP in 2017, in this latest paper they report the six-year outcomes. In total, 60 patients were included in this study and all were subjected to detailed history taking, clinical examination, and routine laboratory investigations in addition to upper GI endoscopy.
For the LGP procedure, patients were placed in an anti-Trendelenburg French position, trocar design was as follows: supraumbilical camera port, two working ports to the right and left of the midline, and an assistant port for liver retraction. Devascularization of the greater gastric curve was started 6 cm proximal to the pylorus using harmonic or ligasure haemostatic devices. Care was taken to take the bites 2 cm away from the gastric wall to avoid thermal injury and potential leakage. Devascularisation continued until reaching a point 2cm from the cardio oesophageal junction. Before plication, a 38Fr bougie was inserted for proper calibration. Plication was performed in two rows (via two anterior and two posterior bites). It was performed using prolene, ethibond sutures or both.
At six-years, an endoscopic evaluation of patients was performed and the plication fold was graded according to the presence of fold continuity: grade A for prominent plication fold and grade B for partial or completely disrupted plication fold.
Postoperatively, patients were asked to rate their hunger sensation between meals using a ten-grade scale (0 no hunger, 10 extreme hunger), as well as report their compliance to regular physical exercise and diet regimen. Weight regain was defined as >25% of EWL and inadequate weight loss was defined as %EWL less than 50% in the first 18 months postoperatively.
From 60 patients (81.7% females), the analysis showed that T2DM was the most prominent-associated medical problem 21(35%), followed by hypertension 9 (15%) and sleep apnoea 6 (10%). Additionally, four patients (6.7%) had gallstones diagnosed preoperatively, and all patients were subjected to concomitant laparoscopic cholecystectomy with LGP.
The mean BMI was reduced from 40.72±7 to 33.75±5kg/m2 at one year (p<0.001), a relative plateau occurred from years two to four, with no significant change in mean BMI (Figure 1). However, from years four to six, a moderate but significant increase in BMI was observed, 35.90±6kg/m2 (p<0.001).
At six years, obesity indicators remained significantly reduced relative to baseline measures. For example, absolute weight was 93.75±16 compared to 108.48±23kg at baseline, a mean reduction of 14.73±17 kg (p<0.001). However, a significant amount of weight regain was evident: the mean %TWL value after six years was 12.08±13.1% compared to 21.1±8.9% after two years. Similarly, the %EWL at six years was 32.04% compared to the two-year level of 60.2%.
During the scheduled follow-up period, inadequate weight loss was observed in 11 (18.3%) patients. Weight regain was observed in 35 patients at six years to reach a rate of 58.3%. Some variables were evaluated to define risk factors for weight regain after LGP at six years: age, sex, weight, BMI, associated medical problems, suture used for the plication, distance from the pylorus, post-operative hunger sensation, de novo GERD, and patient compliance or adherence to diet and regular exercise.
At six years, endoscopic evaluation was done for 50 (83.3%) patients for the condition of the plication fold, and they found a partially or completely disrupted fold in 40 (80%) patients. The risk factors for weight regain at six years after LGP, disrupted plication fold, higher hunger scores and non-adherence to regular exercise and diet were significant factors in the univariate analysis.
At six years, the improvement rate for diabetics declined to 66.6% (14/21). Regarding patients with hypertension, 77.7% described improvement after LGP at two years, while this improvement declined to 66.6% at six years.
After the endoscopic evaluation of 50 patients, only four patients had erosive esophagitis, three of them had grade A reflux esophagitis, and the other one had grade B reflux esophagitis at six years
The authors concluded that further studies with a larger sample size and longer follow-ups are needed to discover the durability of the LGP procedure.
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