Obesity Surgical Options - Position Statement For Sleeve Plication
Bariatric surgery by definition is the surgical science of distorting the proximal stomach and foregut with the aim of reducing intake and perhaps reducing uptake of calories. In this subspecialty, over many years, a number of different procedures have evolved. These different procedures have different safety profiles, follow-up profiles and outcome profiles. The sleeve plication is an emerging procedure that is being adopted by various centres throughout the world and its exact role in the bariatric surgical armamentaria is yet to be defined. The Obesity Surgery Society of Australia and New Zealand supports the idea of new and emerging procedures but cautions both clinicians and patients to be cautious when undertaking such procedures.
Information For Patients
The information below is provided for patients and carers of people wishing to potentially undertake gastric sleeve plication for the management of morbid obesity.
The procedure of sleeve plication could perhaps best be defined as a more simple and safer version of the well established sleeve gastric resection for morbid obesity. Sleeve gastric resection is widely practised throughout the world and its medium term efficacy is certainly well established. The hoped advantage of sleeve plication is to try to achieve similar weight loss outcomes but with less peri-operative risk. There is reasonable evidence that this procedure does have an improved safety profile as there is no removal of the stomach. It is also potentially reversible.
The main issue at this stage is that as a new procedure there is no long-term, or even medium term, about sustained weight loss. The most up to date data suggests that it will likely be successful in the short-term.
The operation is performed by a keyhole surgery, or laparoscopy, and the stomach is mobilised or freed, from its attachments and then the muscle lining of the stomach is essentially tucked into the muscle tube itself. This essentially dramatically reduces the gastric capacity. The portion of the stomach that is plicated is known as the greater curve and this is the portion of the stomach which is able to dramatically expand when one eats. The hope is that in the post-operative period the patients will have the effect of both a marked reduction in their appetite as well as a feeling of very early satiety, or fullness. In terms of weight loss it is our hope that the procedure could aid in losing perhaps half of the excess body weight. The time frame to achieving this will obviously vary from person to person but most weight will be lost in the first 6-12 months.
The gastric plication has a number of perceived benefits over other currently established procedures.
- In contrast to the adjustable gastric band, the plication may permit a more normal food eating pattern with no dysphagic effects.
- The procedure is hopefully safer as there is no transectional cutting of the stomach and the post-operative nutritional deficiencies as a result of the abnormal anatomy should be minimal.
- As there is no adjustability factor, the follow-up protocol, as per the sleeve gastrectomy, should be minimal.
Disadvantages Of The Gastric Plication
- This procedure is not yet proven to work although anecdotal evidence and some of the limited published literature from overseas is promising.
- Most patients suffer quite severe post-operative nausea and this can require fairly prolonged hospital stays and/or readmissions. Patients who suffer reflux may get worsening of their symptoms.
- This operation permanently distorts the stomach and makes any revisional gastric surgical issues very difficult.
As mentioned, the role of sleeve plication remains undefined. It has been used as a primary procedure but also it may have a role as a revisional procedure after failed or complicated previous bariatric procedures.
Currently the OSSANZ executive supports the limited practice of gastric sleeve plication in units with a sub-speciality interest in revisional and high volume primary procedures. It should be done in a setting where outcomes and issues are regularly evaluated and hopefully presented in peer literature.