Comparison of laparoscopic sleeve gastrectomy and laparoscopic gastric plication: One year follow-up results

Abstract

Objective: Various different surgical methods are used for obesity surgery. Among them are laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric plication (LGP), both which have been successively performed recently. In this study, we compared treatment results of patients who underwent LGP with decrease in gastric volume via plication in gastric major curvature and patients who had LSG, a method that was been used earlier than LPG.

Material and Methods: We analyzed all morbid obese patients who underwent bariatric surgery with LSG and LPG in Konya Beyhekim hospital between 2009 and 2012. Demographic features including age and sex, preoperative blood biochemistry, body mass index (BMI) before and after operation, duration of hospital stay, morbidity, mortality and complications were analyzed.

Results: We enrolled a total of 55 patients who were operated for obesity between 2009 and 2012. Among them, 29 patients had LGP, and 26 patients had LSG. BMI in LGP group was 41.4 ±3 kg/m², and LSG grubu was 42.0±3.1 kg/m². There was no significant difference between two groups for BMI. Two groups were also similar for mean age and gender ratios. In LGP group, one patient had postoperative necrosis in suture line. One patient in LSG group was re-operated for bleeding. Another patient in this group had leakage at suture line. In postoperative BMI assessment of LPG and LSG patients, patients who underwent LSG had significantly lower BMI levels. Duration of hospital stay was significantly shorter in LGP group. There was no significant difference in complication rates between two groups.

Conclusion: In this study, we obtained similar results in patients who were treated with LPG and LSG. Moreover, LSG was more efficient to decrease BMI in morbid obesity surgery when compared to LPG. However, duration of hospital stay was significantly shorter in LGP group. We concluded that both methods can be effectively and safely used in surgical management of morbid obesity.

Keywords: Obesity, sleeve, plication, laparoscopic

Introduction

Obesity is generally defined as a body mass index of 30 kg/m² and morbid obesity as being over 40 kg/m². Obesity emerged as a serious health problem in recent years due to the rise of the welfare in the society and malnutrition issues related to the modern lifestyle. Approximately 1.7 billion people worldwide suffer from obesity related serious health problems. The incidence of morbid obesity is reported as 3-5% in Western societies. Obesity has a mortality rate of approximately 0.1% in developed countries and leads to major healthcare cost. Morbid obesity related mortality often appears to be due to cardiovascular causes (1-4).
Bariatric procedures that have been implemented since the 1950s improved with both experience and technique over the years. With the introduction of laparoscopy to the surgical agenda in the 1990s, minimally invasive surgical technology began to be applied in bariatric surgery. Malabsortive methods, restrictive methods or their combinations are being applied for the surgical treatment of obesity. Gastric banding and laparoscopic sleeve gastrectomy (LSG) are two popular restrictive methods that have been applied to the present day for the surgical treatment of morbid obesity. In recent years, laparoscopic gastric plication (LGP) was introduced as another restrictive method in bariatric surgery. In this study, we aimed to compare LSG that is commonly used in the surgical treatment of morbid obesity with the recently introduced and popularized LGP (5-7).

Material and Methods

All patients who underwent LSG or LGP due to morbid obesity at Beyhekim Konya Hospital General Surgery Clinics by a single surgeon between the years 2009-2012 were retrospectively analyzed. Age, sex, and BMI on admission were evaluated. Preoperative levels of fasting blood glucose, aspartate aminotransferase (AST), alanine aminotransferase (ALT), triglycerides, cholesterol, and blood pressure were determined to investigate the presence of metabolic problems. The length of hospital stay was determined for both groups. All patients who underwent surgery were included.
Indications for operation were specified as patients with BMI 35 kg/m² and above along with medical problems such as hypertension, diabetes mellitus and sleep apnea, and patients with BMI of 40 kg/m² and above. All of our patients have previously tried diet, medical treatment and did not get satisfactory results from lifestyle changes, behavior modification and other conservative methods, and have failed to lose sufficient weight.
Surgery was performed under general anesthesia in patients who underwent LSG. An intra-abdominal pressure of 12 mm-Hg was created. 10 mm trocars were placed in the subxiphoid, umbilical and the right subcostal-midclavicular line (for liver retraction), a 12 mm port in the left subcostal-midclavicular line (for stapler introduction), and a 5 mm trocar in the left subcostal-midaxillary line. The greater curvature was mobilized from the gastric fundus, down to 4-6 cm from the pylorus by using Covidien® LigaSure. Then with 42F bougie guidance, the stomach was resected vertically including the fundus, 4-6 cm from the pylorus. Hemostatic sutures were placed when required. A silicon drain was placed in the abdomen in all patients. Liquid foods were introduced on the postoperative 3rd -4th days.
In patients who underwent the other surgical method, LGP was performed under general anesthesia with an intra-abdominal pressure of 12 mm-Hg. 10 mm trocars were placed in the umbilicus, the left subcostal-midclavicular line and the right subcostal-midclavicular line (for liver retraction), 5 mm trocars in the subxiphoid and left subcostal-midaxillary line. The greater curvature was mobilized until the gastric fundus, 4-6 cm from the pylorus by using Covidien® LigaSure. With guidance of a 42F bougie, interrupted 1.0-26 mm silk sutures were placed from the pylorus to the fundus. The suture distances were set to be 2.5 cm and inward plication of the stomach was performed through the greater curvature. A silicone abdominal drain was placed when required. Liquid foods were started on postoperative day 2.
Wound infection, nausea and vomiting lasting for less than a week, atelectasis, hemorrhage treated with conservative approach, and non-life-threatening complications improving by medical treatment were considered as minor complications. Intra-abdominal abscess, intestinal leakage, bleeding requiring transfusion, pneumonia, acute respiratory distress syndrome, nausea and vomiting lasting longer than a week were considered as major complications. All patients were observed in the surgical intensive care unit on the first postoperative day. All patients operated by both techniques were evaluated in the first, sixth, and twelfth month and their follow-up data, particularly BMI, were recorded.
Statistical Analysis
Statistical Package for the Social Sciences (SPSS) for Windows 15 (SPSS® Inc., Chicago, IL, USA) was used for data analysis. Descriptive statistical analysis was performed. The Student t test was used to assess the difference between the groups. p <0.05 was considered to be significant.

Results

All 55 patients who underwent these operations were included in the study. Our study group consisted of 44 men and 11 women. The mean age was found to be 34.8±10.7 years. The mean body mass index of all patients was 41.7±3.0. The 29 patients with LGP constituted Group 1, and the 26 patients with LSG were called Group 2. There were 23 males and 6 females in Group 1. The mean age of Group 1 was 35±11.2 years. There were 21 male and 5 female patients in Group 2, with a mean age of 33.9±10.9 years. There was no statistically significant difference between the two groups in terms of mean age (p=0.581) and gender (p=0.763). The preoperative BMIs were 41.4±3.0 and 42.0±3.1 in Group 1 and Group 2, respectively. There was no statistically significant difference in terms of BMI between the groups (p=0.482) (Table 1).

Table 1. Groups according to age-gender and BMI

Table 2. Preoperative biochemical parameters and arterial systolic blood pressure value

Table 3. Comparison of LGP and LSG complications

Table 4. Comparison of length of hospital stay and BMI in Group 1 and 2

Discussion

Although the main etiologic factor is still controversial, genetics and environmental factors play a common role in the etiology of morbid obesity. One of the most common fatal complications of morbid obesity is sleep apnea, and medical treatment does not usually offer cure. Other major problems emerging in morbid obese patients can be listed as hypertension, dyslipidemia, diabetes and diabetes-related coronary disease, gastroesophageal reflux disease, degenerative arthritis and menstrual disorders in women (2, 8-10).
Currently, there are both medical and surgical options for the treatment of morbid obesity. Diet, lifestyle changes, intragastric balloon implementation, methods such as drugs that reduce appetite and disrupt absorption are being tested for the medical treatment of morbid obesity. Prior to surgery, a trial of medical treatment is widely accepted, despite its limited success (5, 11-13).
Surgical treatment of morbid obesity has been proven to provide long-term weight loss, and to improve morbid obesity related serious co-morbidities as well as quality of life. Many of these problems associated with morbid obesity either completely disappear or decrease with weight loss. The improvement with bariatric surgery in diabetes is reported as 76.8%, in hypertension as 61.7%, in hyperlipidemia as 83.6%, and in sleep apnea as 70.0% (2, 8-10).
Surgical treatment is recommended for patients with a BMI ≥40 kg/m² or with BMI ≥35 kg/m² along with co-morbidities when other treatment options fail (NIH Consensus 1991). Among the surgical treatment methods used are gastric and intestinal bypass, biliopancreatic diversion, band gastroplasty, sleeve gastrectomy and gastric plication. A 10-15% increase in patient survival is reported after a successful surgery. The implementation of morbid obesity surgery in experienced centers appears to have an approximately 1-2% mortality rate (7, 14-19). Surgery for morbid obesity is improving every day. The issue on which surgical method is more effective is still controversial. Therefore, our study aimed to identify the efficacy of LGP and LSG in the surgical treatment of morbid obesity and to reveal their superiority over each other.
There are numerous studies on LGP and LSG in the literature. Felberbauer et al. (20) applied LSG in 126 patients with an average follow-up of 19.1 months, and they detected more than 50% excess weight loss (EWL) in 64% of patients. However, in 7% of patients the EWL was below 25%. In their study, the only major complication was a staple line leak in one patient. Felberbauer et al. (20) stated that the effect of LSG was not clear in patients with morbid obesity, due to inadequate results obtained in 7% of patients. Noun et al (21) performed LSG on 122 obese patients between 2010-2012, and they reported a decrease in BMI from 33.2±2.5 kg/m² to 24.7±2 kg/m2 by the twelfth month. They identified severe staple line leakage in 1.3% of patients, mild staple line leakage in 0.5%, and mortality in 0.1%. They stated that the LSG method is a successful and safe method. In the LSG group in our study, one patient developed a serious leak in the staple line, and another was re-operated for bleeding. There was no mortality in our patients. The BMI of our patients showed a steady decrease during postoperative follow-up at one, six and twelve months. In the LSG group, a reduction was detected from 42±3.1 kg/m² to 26.0±1.8 kg/m² on the 12th month. The BMI reduction in the LSG group was found to be successful in terms of surgical treatment of morbid obesity (21-23).
Atlas et al. (24) applied LGP to 44 patients in 2011-2012. The EWL was found to be approximately 50.7% on twelve months, and they concluded that LGP is a successful method in terms of weight loss in patients with morbid obesity. However, in the same study, nausea and vomiting was detected within the first ten days in 79.5% of patients, and 25% of patients had to be re-hospitalized for refractory nausea and vomiting. Therefore, they emphasized the incidence of nausea and vomiting and associated readmissions as drawbacks of this method. In the present study, we evaluated BMI postoperatively in the LGP group. The initial BMI of 41.4±3.0 kg/m² was identified to be 27.3±2.0 kg/m² on the twelfth month. The results were satisfactory and consistent with the literature in terms of weight loss (13, 18, 25). The postoperative nausea and vomiting in our LGP patients was less frequent than that reported by Atlas et al (24). Only five of 29 patients (17.2%) had nausea and vomiting in our series. These symptoms resolved with medical methods or short-term hospitalization.
In their 2013 study, Dijian et al. (26) compared LSG and LGP in 39 patients. The mean length of hospital stay was 4.2±1.9 days in the LGP, and 3.9±1.7 days in the LSG group. There was no significant difference between the groups in terms of length of hospital stays, while it was concluded that LSG method was more effective in terms of weight loss than LGP method based on BMI follow-up data on postoperative first, third, sixth months. Abdelbaki et al (27) have published a similar study carried out with 140 patients in 2014. They evaluated their treatment with EWL in the sixth and twelfth months. The twelfth month EWL values in the LGP and LSG groups were 52.1±15.1% and 68.1±15.8%, respectively, in favor of LSG. Therefore, they concluded that LSG was more efficient in the treatment of morbid obesity. They found the length of hospital stay to be longer in the LSG group. In our study comparing LGP and LSG, the reduction in BMI was significantly more in the LSG group in the twelfth month. However, there was no significant difference between the 2 groups in comparison of first and six-month BMI values. Length of hospital stay in LGP and LSG groups were 3.2±0.5, 5.5±0.8 days, respectively. In our study, the length of hospital stay was significantly less in the LGP group as compared to the LSG group, similar to Abdelbaki et al. (27).
The results obtained in our study are consistent with many studies in the literature. However, the low number of patients (55 patients), short follow-up period (12 months), and the retrospective nature are limitations of our study.

Conclusion

Laparoscopic gastric plication method is a new method that was popularized after LSG in the surgical treatment of morbid obesity. We found that LSG was more effective than LGP for the surgical treatment of morbid obesity. However, LGP is a good alternative in the surgical treatment of morbid obesity with shorter length of hospital stay, an easier technique and reversibility. New randomized trials with long-term follow-up are needed in order to obtain results that are more precise.

Since it is a retrospective study, we did not apply for ethical committee approval.

Written informed consent was obtained from patients who participated in this study.

Externally peer-reviewed.

Concept - Ş.S.T., Y.G.; Design - Ş.S.T., Y.G.; Supervision - Y.G., A.O.; Funding - Y.G., A.O.; Materials - Ş.S.T., Y.G.; Data Collection and/or Processing - Ş.S.T., Y.G.; Analysis and/or Interpretation - Y.G., A.O.; Literature Review - Y.G.; Writer - Y.G.; Critical Review - Ş.S.T., Y.G., A.O.; Other - Ş.S.T., Y.G., A.O.

No conflict of interest was declared by the authors.

The authors declared that this study has received no financial support.

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