Laparoscopic greater curvature plication - a new and safe bariatric procedure.

Morbid obesity is affecting an increasing number of people worldwide and when clinical treatment does not achieve the expected results, bariatric surgery becomes the last resource. Laparoscopic greater curvature plication (LGCP) is a new bariatric restrictive procedure that avoids the complications linked with the permanent implant of an adjustable gastric ring (oesophageal laceration, gastric erosion) while also minimizing the possibility of leaks associated with sleeve gastrectomy. Also known as gastric imbrication and total vertical sleeve plication, the procedure consists of reducing the gastric volume by placing at least two rows of nonabsorbable sutures on the greater gastric curvature. Having as forerunners an open technique tried in 1968 [1] and the StomaphyX [2] device used in reducing a large stomach pouch after unsatisfactory bariatric procedures, LGCP was first described in 2007 [3]. Trials were initiated in the USA in 2009 and the first paper was published in 2010 [4]. Our personal experience is limited to 3 cases. The standard 5 trocar approach starts with the dissection of the angle of His. The greater curvature is dissected with a bipolar forceps leaving the vascular arcade intact. Posterior gastric adhesions have to be freed in order to achieve an adequate mobility. The first row of interrupted extramucosal non-resorbable stitches is calibrated on a 32-40-Fr bougie. The second continuous suture suffices to reduce adequately the gastric volume. No gastric aspiration tube and no dye leakage tests are necessary. Nausea, vomiting and sialorrhea may affect up to one third of the patients during the first two weeks [3, 4]. A liquid diet is started as soon as it can be tolerated, gradually switching to solid food after two weeks. Proton pump inhibitors are recommended for 60 days. Follow-up visits should be scheduled after 1 week, 1, 3, 6, 12 and 18 months. Although the available data offer only studies on a low number of patients, the results are very good. The mean hospital stay is less than 48 hours, with return to activity in 7 days [4]. The leaks are exceptionally rare [3] and no other complications are yet reported. Another advantage is the low conversion rate to the open procedure. The loss of excess body weight reaches 20% at 1 month, 32% at 3 months and stabilises at 60% at one year [3, 4], figures comparable to those obtained with other restrictive procedures (adjustable gastric ring, sleeve gastrectomy). The evolution is not affected by weight regain. Upper endoscopy or barium swallow are not mandatory, unless symptoms of reflux are present. The imbricated gastric fold is smaller at 6 months compared with the evaluation at 1 month and remains unchanged after a longer period. The lumen size appears also unaffected by dilation [4]. Laparoscopic greater curvature plication is a safe and efficient bariatric procedure that prospective trials and a longer follow-up should confirm in order to gain wider acceptance.