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Mohammad Talebpour

Gastric plication: the first 12 years

Operation offers lowest complication and reoperation rate out of restrictive methods
Mean EWL 70% after 24 months; 55% after five years
Dr Talebpour (above) used his experience of 800 cases to emphasise the safety and low cost of his technique.

Mohammad Talebpour, who devised the laparoscopic gastric plication, has published a paper detailing the results from his first 12 years using the technique, reporting impressive weight loss and a low complication rate, but highlighting a trend towards weight gain after several years.

The paper, “Twelve year experience of laparoscopic gastric plication in morbid obesity”, looked at 800 gastric plication cases that the Tehran-based Talebpour and colleagues have performed, with an average follow-up of five years. He found that the mean excess weight loss was 70% (40% to 100%) after 24 months and 55% (28% to 100%) after five years, which he described as “comparable” to other restrictive methods.

Talebpour also emphasised the safety and low cost of the technique, stating that it costs US$2,000 less than gastric banding or sleeve, and US$2,500 less than gastric bypass.

Outcomes

The mean pre-operative BMI among patients was 42.1 (ranging from 35-59). Mean EWL was 20% after one month, peaking at 70% after two years, and dropping to 55% after five years and 42% after ten years. Weight loss increased when a second row of plication was added (See figure 1).

Figure 1: total %EWL for patients up to six months. Source: Talebpour et al, Twelve year experience of laparoscopic gastric plication in morbid obesity

The average anatomic volume of the stomach after the operation was 100cc in one-row plication patients, and 50cc in two-row plication patients. However, the functional volume of the stomach in one- and two-row plication respectively was around 25cc and 15cc initially, 50cc and 25cc after two weeks, 75cc and 45cc after six months, 100cc and 60cc after one year, and 250cc and 150cc after four years.

11% of patients had diabetes at the start of the study; of these, 95% had gone into remission.

Common complications included mild to moderate weakness for the first three months post-operation; epigastric pain was seen in 35% of cases, but was treated with antacids. Vomiting was seen in all cases for at least four hours, and reflux was seen in 16% of cases.

Post-operative technical complications were seen in eight cases out of the 800 presented.

Micro perforation occured in three cases, and three patients sufferend from post-operative obstruction, caused by the displacement of the released fundus outside the suture line, stretching the string and over-tightening the the knots.

In one case, an unusual adhesion between the fundus and the liver caused permanent vomiting and discomfort until a reoperation resolved the problem.
All of the complications bar two were seen when the one-row plication technique was used: when the two-row technique was used (in 644 out of 800 cases), the complication rate dropped dramatically.

Talebpour noted that all technical complications occurred within the first week after operation: if no complications were found at this point, there was no risk of complication later on.

The mean time of the operation was 72 minutes, which dropped to 67 minutes when the dissection of the greater curvature was done by LigaSure or Ultracision.
Talebpour reported the price of hospitalisation and instruments used in the operation at US$2,000; he compared this price a cost of US$4,500 for gastric bypass and US$4,000 for sleeve or banding.

Regain

31% of patients experienced weight regain (defined as a cumulative excess weight loss dropping to under 30%) after eight years.

Talebpour said the main reason for regain was an incorrect selection of technique, with males without good motivation and not demonstrating co-operation making up most of the regain cases.

The second most common group who regained weight was those who had initially good results, but who experienced a change in their situation which made motivation and co-operation difficult.

Patients

Talebpour selected patients for the procedure based primarily on their motivation and co-operation, looking for the potential for motivation and co-operation; the majority of patients were young single females with a history of obesity during adolescence and a dislike of their weight at the time of the operation. Those with moderate and low motivation were offered gastric bypass and duodenal switch, respectively.

For the first few years of experience, only patients aged over 18 were selected, but as the technique was practised and refined, some well-suited adolescents as young as 12 were chosen.

In the case of weight regain, a second stage procedure was advised after four years, ordinarily adding a laparoscopic malabsorptive method.

Patients were initially discharged 24 hours after the operation, but this was increased to three days to allow intravenous fluid intake. During the first six weeks, no solid food was allowed.

Evolution

Figure 2: the evolution of the gastric plication technique. Source: Talebpour et al, Twelve year experience of laparoscopic gastric plication in morbid obesity

Talebpour trialled four plication techniques in animals before the final version was chosen as the safest and most effective method (Figure 2). This was trialled in volunteers in the year 2000, and three further modifications created an acceptable single-row plication method. However, the more secure two-row plication method was developed to prevent bulging of the plication out of the suture line.

As Talebpour practiced the operation, the rate of regain dropped: he blamed the 42% 10-year regain rate in the first 35 operations on the surgical learning curve, the one-row method, and suture bites too far away from the lesser curvature.

Talebpour concluded by listing the advantages of the operation as he saw them. He stated that it has the lowest rate of reoperation among restrictive techniques: 1% in the first week, and less than 0.2% thereafter. He compared this to a 10-20% incidence of emergency band removal in gastric band surgery, or the 10% complication rate, including leakage, disruption, and malabsorption, in sleeve gastrectomy.

Follow-up is also easy, with no obligatory post-operative procedures, and the low quantity of foreign bodies needed reduces the cost of the operation and reduces the chance of a poor reaction. The operation is also easily reversible up to six weeks.

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