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Greater Curvature Plication

The gastric sleeve has made bariatric surgeons realize that one of the best techniques for weight loss is to create a long vertical pouch (thus the name vertical weight loss solutions on the web site logo). In this light over the last few years a technique of placating (folding) the stomach into itself (invaginating), in a vertical fashion, creating a long gastric tube has been performed. The formal term is Laparoscopic Greater Curvature Plication (LGCP). We describe it as a pseudo- sleeve. The steps involved are the same as that of the gastric sleeve until it comes time to transect and remove the stomach. In the gastric plication the stomach is folded into itself using two layers of sutures or clips. The stomach isn’t transected or removed, there are no staple lines to cause complications such as leaks or bleeding, and the end result of the tube mimics the long gastric tube of the sleeve.

Complications

Nausea for the first few days is common as a result of the edema (swelling) caused by the invagination of the gastric tissue.If the swelling persists or the tube has been created too narrowly or twists, obstruction may occur, necessitating a reversal of the plication or possibly even resulting in conversion to a gastric sleeve or a gastric bypass.Gastric perforations or leaks are also possible as a result of the swelling or ischemia (poor blood supply) caused by the plication.Bleeding and ulceration of the stomach may also occur as a result of poor blood caused by the invagination of the gastric tissue.
Results

To date there are no long term studies. Preliminary results are encouraging and show similar weight loss to the gastric sleeve. Resolution of the co-morbidities is also unknown.

The effects of the plication on the gut hormones (that the gastric sleeve affects) are unknown.

Combination of greater curvature plication with Nissen Fundoplication

Nissen Fundoplication is a well established procedure since the 1950’s for the treatment of hiatal hernias and/or Gastro-Esophageal Reflux Disease (GERD, reflux). This operation entails closing the hiatal hernia (the opening in the diaphragm where the esophagus enters the abdominal cavity is enlarged, allowing the stomach to move up into the chest) and then plicating (wrapping) the stomach around the esophagus to act as a valve that doesn’t let the acid or bile reflux into the esophagus. One of the steps of this procedure is mobilization of the upper part of the greater curvature of the stomach so that the plication around the esophagus is easy and floppy without tension. To perform a LGCP, we can easily extend the mobilization to the lower part of the stomach.

One of the drawbacks of a gastric sleeve is that it may worsen or cause reflux in approximately 10-15% of patients. Because of this, over the past year we have been combining the fundoplication with a greater curvature plication in obese patients that have significant reflux. This operation results in the treatment of reflux and in significant weight loss. The complications are the same as for a gastric plication and again, there are no long term results. Short term results bear out the cure of the reflux and the weight loss appears to be similar to the sleeve. In the limited number of patients we’ve done, Type II diabetes also appears to be significantly improved or cured. We have had a patient in whom the plication twisted and required reversal.



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