Today at MISS 2012 – the Minimally Invasive Surgery Symposium in Salt Lake City, Utah – the morning opened with 4 sessions focused on gastric plication: an investigational and experimental procedure. Dr. Ariel Ortiz, who has done 400 gastric plications – one of the largest studies so far – began the session by speaking about the technique of performing this surgery. He highlighted that plication is a stomach-sparing procedure, meaning that no part of the anatomy is removed. Dr. Ortiz discussed the first group of cases he did and the complications, followed by change that were made for the second group. The second group of cases had lower complication rates (1% vs 5%), significantly less vomiting (7% vs 34%), and higher excess weight loss. In addition to performing plications as primary procedures, Dr. Ortiz spoke about a set of patients in which plication was done as a revision to a gastric band. Overall, this has not been successful and he now does not perform plication after a failed band. In closing, Dr Ortiz emphasized a strong need for appropriate pre-op testing, standardization of the technique, and long term follow-up.
The second speaker was Stacy Brethauer MD of Cleveland Clinic, who gave a review of the existing literature on plication. He began by showing a video and contrasting initial plication technique versus the technique after improvements were made. With exciting early results from the small amount of existing data (62% EWL at 18 months from one cited study), Dr. Brethauer believes that plication will ultimately show weight loss amounts between the gastric band and sleeve, and that it’s likely not the best procedure for patients with the highest BMI’s. The high level of EWL shown have primarily been from patients with lower BMI’s (generally 30 – 40). He believes that based on the current literature, it is reasonable to expect that 10 – 20% of patients will have inadequate weight loss with this procedure, or a failed procedure (the plication coming undone, resulting in the stomach reverting to its original volume). Dr Brethauer concluded by saying it appears that the greater curve plication is feasible with good short-term weight loss. He emphasized that this is still investigational, and pointed out that it has not been found to have positive metabolic effects at this point.
The last speaker was Dr Daniel Cottam of Bariatric Medicine Instutite, who presented about his experience doing banded plication: a new, investigational procedure that combines a gastric band with gastric plication. Dr. Cottam likes that this combination can provide benefits from both procedures, and allows them to complement each other. For example, the band slows down how fast people can eat, whereas the plication decreases the volume people can eat. In addition to the compounding of benefits, when you combine two procedures you have to expect that the complications from each procedure can be seen, and Dr. Cottam says this is the case. However, one relatively common gastric band complication may be helped by the addition of plication: with banded plication, there appears to be a reduction in band slips. Dr Cottam says banded plication seems to offer better weight loss than gastric band along, and the potential for fewer band fills, although follow up is still very important to long-term success. “The Bandication (banded plication),” Dr Cottam told us after his presentation, “is an exciting new procedure that all researchers and early adopters agree provides better weight loss than the band alone. While there is little agreement yet on standardization of the technique, all techniques and surgeons who are doing the procedure are showing favorable results.”
To close the session, Dr Phil Schauer led a debate among the speakers – with the addition of Dr. Nihn Nguyen – about whether or not plication is ready to be considered a mainstream procedure. Among the concerns presented about plication are: lack of reproducibility, no evidence of metabolic effects, and that currently, only a small amount of data is available. For more information, you can read the ASMBS gastric plication statement.
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