2. Experience with 458 cases of Gastric Plication Surgery Dr Ariel Ortíz Lagardere,FACS. Obesity Control Center hospital, México

3. New procedure? Similar to sleeve gastrectomy Stomach Sparing Less risk leak No need implant/adjustments/stapling Literature can be found early 1900’s 2001 Dr Talebpour. Ortiz-Lagardere, MISS 2012

4. Band/Plication per Month Ortiz-Lagardere, MISS 2012 Presented IFSO 2011.

5. Patients 458 total (07/2010 to 12/2011) Primary/Revision : 429/29 Gender : 370 Female, 88 male Age: 42.7 years (Range 16-71) Ortiz-Lagardere, MISS 2012

6. BMI

7. Gastric Plication N=458 Surgical time 41 min. ( 26 to 145 min.) Hospital stay 23 hours ( 6 hrs. to 5 days) 0% mortality 0% conversion 2% Re-operation 8% “Re-plication” Ortiz-Lagardere, MISS 2012.

8. Early Symptoms after Gastric Plication Surgery OCC Ortiz-Lagardere, MISS 2012

9. Symptoms 1 to 8 weeks after surgery 25.3% Ortiz-Lagardere.

10. “Acid Reflux” After 6 month follow-up of 278 patients, 68 (24.4%) of patients reported persistent heartburn 37 patients continuous PPI 27 Intermittent use of PPI or other antacids 4 severe (2 resulted in re-operation) Disphagia to solids 2%

11. %EWL Primary Plication 182

12. % EWL longitudinal assessment Jul/10 to Aug/11 272 patients (Primary Plication) 48.5% 53.4% Patients 7 25 23 31 37 35 41 39 34 Ortiz-Lagardere, Presented in IFSO 2011

13. Co-morbidities at 6 months Patients diagnosed with: Type II Diabetes High blood pressure Sleep apnea Asthma TotalNo ChangeImprovementRemission 4721926 3851320 2911018 15492

14. Complications Early 9 obstructions (6 surgical). 2 bleeding (short gastric vessels) 1 Intolerance persistent hiccups' 1 wall hematoma 1 sub-diaphragmatic lymphatic collection. Ortiz-Lagardere, MISS 2012

15. Complications Delayed 9 Bleeding ulcers (2 to 6 months after surgery) – 5 Transfusion – All: sucralfate and PPI 2 perforated ulcers – Distal gastrectomy 1 gastric wall hernia (ischemia, no perforation). – Reversal No obstruction. Ortiz-Lagardere, MISS 2012

17. Gastric plication suture line hernia

18. Large ulcer in plicated antrum

20. 29 patients LAGB conversions 27 female, 2 male Age 44 years BMI 38.7 Kg/m² Surgery time 68 min Mortality 0% Morbidity 1 obstruction 15 (52%) Plication revisions 1 conversion to LAGB. %EWL 32% Revisions from LAGB Ortiz-Lagardere, MISS 2012

21. “Re-plications” Total 36 patients (34 female/2 male) 15 conversions from LAGB Chief complaint : loss of restriction Surgery Time 55 min ( 25 to 220 minutes) Complication 0% Hospital stay 22 hours

22. “Re-plication” 67 patients 218 patients

23. “Re-plication” 10 patients 16 patients

24. Surgical Technique Plication of the stomach Where to start, proximal to distal or distal to proximal? One, two or three suture planes?. What are the ideal suture material(s) for each plane? Size bougie and calibration?

25. Laplace’s Law The tension on the wall of a sphere is the product of the pressure times the radius of the chamber and the tension is inversely related to the thickness of the wall. Ortiz-Lagardere, IFSO 2011

26. Sutures in plication surgery OCC time linetechnique August 103 Planes (2-0 Ethibond interrupted, 2-0 Prolane continuous, 2-0 Prolane continuous), Angle of His to 4 cm from pylorus. All sutures sero-muscular SeptemberNo Change October2 Planes (2-0 Ethibond interrupted 1.5 centimeters separation, 2-0 Prolane continuous ), Angle of His to 4 cm from pylorus. NovemberEthibond plane les than 1 centimeter of separation between sutures. DecemberProximal “limiting suture” 2-0 Ethibond previous full removal of gastro-esophageal fat pad. Second suture plane continued until 1-2 centimeters from pylorus JanuaryNo Change FebruaryIncreased caliber of Prolane to 1-0 and placement of polymer clip on distal Prolane anchor. MarchNo Change AprilEthibond 1rst plane performed with 3 to 4 centimeters of separation between sutures May-JuneNo Change July-AugustNo Change September1rst plane changed to continuous absorbable Monocryl 2-0 suture and looser gastric fundus OctoberNo Change

27. 1 st Ethibond Plane 1cm apart

28. 1 st Plication plane 3 to 4 cm apart.

29. 2 nd Plane 1-0 Prolane

30. Distal anchor polymer clip

31. Symmetry and sleeve like stomach.

32. The learning curve Aug. 2010- Feb. 2011 150 Plication (18 revision) Surg. Time: 54 minutes Hospital stay: 28 hr. Mortality 0% Complication – Early 5% Postoperative nausea and or vomiting 34% 5 Re-operation for obstruction 24 Re-plication Mar. 2011-Jul 2011 250 Plication (5 revision) Surg. time: 37 minutes Hospital stay: 21 hr. Mortality 0% Complication – Early 1% Postoperative nausea and or vomiting 7% 1 reoperation for obstruction Ortiz-Lagardere, IFSO 2011

33. Technique Requirements Symmetrical Start at the Angle of His Containment suture Evenly spaced suture Even pressure calibration Distal plication Ortiz-Lagardere, IFSO 2011

34. com plication Ortiz-Lagardere, IFSO 2011

35. Conclusions Still experimental Requires standardization of technique Requires long term follow-up Study mechanisms Ortiz-Lagardere, MISS 2012

36. Conclusions Low complication rate Acceptable short term weight-loss Long learning curve Surgeon dependent Patient acceptance Ortiz-Lagardere, MISS 2012

37. Thank you.