Laparoscopic gastric plication in patients with poor outcome after adjustable gastric banding: technical feasibility and preliminary results

Background: Laparoscopic adjustable gastric banding (LAGB) is one of the most widely performed surgical procedures for morbid obesity, allowing to obtain up to 55% of %EWL. There is however a wide group of patients with %EWL ranging between 25% and 50%, where an increase of the effect of LAGB could be useful. Laparoscopic gastric plication (GP) is a new restrictive procedure that does not to require gastric resection, is reversible, and can be added to LAGB because increases the restrictive effect avoiding to contaminate the prosthesic material. A synergistic effect may be obtained because LAGB reduces the esofagogastric transit, while GP reduces the gastric volume. Our aim was to evaluate the effect of GP in patients who had experienced scarce weight loss after LAGB and needed revisional surgery. Methods: 5 patients with scarce weight loss after LAGB needed revisional surgery for band slippage (two patients), tube disconnection in peritoneum (one pt), band rupture (one pt), scarce weight loss (one pt). They underwent GP in addition to band revision to increase the effectiveness of LAGB. Surgical technique: two 5 mm and two 10 mm trocars were inserted, as in usual LAGB operation. After band revision, a greater curvature omentectomy was done with the Harmonic™ scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio), from the antrum (3–4 cm from pylorus) to the angle of His. The GP was then created on the guide of a 32-Ch bougie, invaginating the greater curvature with a first row of interrupted stitches of 2–0 Polypropylene. A second row of running suture of the same material was done over the whole length of the first one. A methilene-blue test was done and a drain was left near the plication. Results: The postoperative course was uneventful, except a slight nausea in the first few days. A Gastrografin® swallow on the first postoperative day showed a slow gastric transit, the band in place and the tubular shape of the plication clearly visible. The patients were discharged on the 3rd postoperative day on a liquid diet, and resumed a solid diet within 4 weeks. The mean preoperative BMI was 37.3±5.19. After 3 months, with the bands still uninflated, all patients lost weight, %EWL was 18.6±16,9. No symptoms of vomiting or reflux were observed. Conclusions: Surgical revisions are frequent after LAGB, in a range of 5-32%: main causes are pouch dilatation or connecting tube complications. In case of need of band revision, a %EWL lower than 50% may be an indication to GP. In our experience the surgical procedure in association with revision of LAGB is feasible and safe, and preliminary results with this new technique show restart of weight loss and recovery of patient’s motivation