Surgery for Obesity and Related Diseases 11 (2015) 733–734
Letter to the Editor
An insight on the superior outcome of sleeve gastrectomy over gastric plication To the Editor, I am writing in response to the letter addressed to your journal, titled “Is excision of the gastric mucosa responsible for the superior outcomes of sleeve gastrectomy compared with gastric plication?” We have been studying laparoscopic gastric plication (LGP) for the past couple of years; our first report was a review article, and it indicated that LGP could be an effective standalone bariatric procedure [1]. This in turn prompted us to start 2 parallel studies. The first was a retrospective study of 140 patients [2] and another is a prospective, randomized study that is still in the process of being published. Both studies were designed with an aim to compare LGP with laparoscopic sleeve gastrectomy (LSG). The reason we chose LSG as a comparative arm was due to the fact that both procedures potentially have the same restrictive effects by reducing the gastric volume. In the retrospective study we found that, over the first couple of months, the pattern of weight loss was similar between both groups; it wasn’t until the sixth month after surgery that we started seeing a significant difference in favor of LSG. It seemed that LSG was more consistent than LGP and that LGP started losing its momentum past six months. We attribute this to 2 main causes. First, after LGP the in-folded mucosa could potentially atrophy or shrink with time and this could in turn result in an enlargement of the gastric residual volume. Although both procedures were calibrated over the same sized calibration tube, one must consider that volume reduction in LGP is mostly caused by the “space-occupying effect” of the mucosal in-folding. Eventually, this in-folding may tend to shrink and hence lose its filling effect. This was noted in a number of patients who came back more than 1 year after their primary surgery complaining of weight regain. Patients were subjected to an upper gastrointestinal endoscopy, which was compared with their immediate postplication endoscopy. We found that there was a moderate degree of atrophy in the mucosal
in-folding with a relative increase in gastric volume. The second reason for the higher weight loss seen with LSG could be related to the fundamental difference between the 2 procedures, where a gastric resection is performed in the LSG, while in LGP no resection is attempted. The removal of the gastric fundus was found in several studies to reduce the levels of the orexogenic hormone, ghrelin [3–5]. This in turn may give the LSG an edge over LGP, in having not only a restrictive component for weight loss but also a metabolic effect. These results were similar to our yet-to-be-published prospective study comparing LGP with LSG. Both studies found a more significant and consistent weight loss pattern in the LSG group. On the other hand, in the LGP group, patients with a lower body mass index (BMI o35 kg/m2) achieved a more sustained weight loss and this was reflected in a higher level of satisfaction. In conclusion, LGP seems to be more effective in patients with a lower BMI. Moreover, it may be unfair to compare LGP with LSG because the latter seems to have more than one mechanism to aid in weight loss. Finally, LGP is still in its infancy and there is a lack of standardization in the technique of plication, which could lead to conflicting results between different authors. Tamer N. Abdelbaki, MD, MRCS Department of Surgery University of Alexandria Faculty of Medicine Alexandria Egypt
References [1] Abdelbaki TN, Huang CK, Ramos A, Neto MG, Talebpour M, Saber AA. Gastric plicationfor morbid obesity: a systematic review. Obes Surg 2012;22(10):1633–9. [2] Abdelbaki TN, Sharaan M, Abdel-Baki NA, Katri K. Laparoscopic gastric greater curvature plication versus laparoscopic sleeve gastrectomy: early outcome in 140 patients. Surg Obes Relat Dis 2014;10 (6):1141–6. [3] Wang Y, Liu J. Plasma ghrelin modulation in gastric band operation and sleeve gastrectomy. Obes Surg 2009;19(3):357–62.
http://dx.doi.org/10.1016/j.soard.2015.03.005 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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T. N. Abdelbaki / Surgery for Obesity and Related Diseases 11 (2015) 733–734
[4] Langer FB, Hoda MAR, Bohdjalian A, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg 2005;15 (7):1024–9. [5] Peterli RL, Wölnerhanssen B, Peters T, et al. Improvement in glucose metabolism after bariatric surgery: comparison of laparoscopic Roux-
en-Y gastric bypass and laparoscopic sleeve gastrectomy: a prospective randomized trial. Ann Surg 2009;250(2):234–41.
http://dx.doi.org/10.1016/j.soard.2015.03.005