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Clinical case
Revision bariatric surgery after endoscopic sleeve gastroplasty
Revisión quirúrgica bariátrica tras gastroplastia vertical endoscópica
Manuel Ferrer-Márquez
Corresponding author
manuferrer78@hotmail.com

Corresponding author at: c/ Valencia, 5, 04007 Almería, Spain. Tel.: +34 6496 84463.
, Manuel Ferrer-Ayza, Francisco Rubio-Gil, María José Torrente-Sánchez, Antonio Martínez Amo-Gámez
Equipo Obesidad Almería, Hospital Mediterráneo, Almería, Spain
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reduces the stomach by trying to imitate a laparoscopic sleeve gastrectomy through a series of transmural stitches from the gastric lumen&#44; following a hands free technique and placing the stitches very close to one another&#44; from the prepyloric antrum up to the gastroesophageal junction&#46; The POSE&#44; in contrast&#44; folds the stomach in 8&#8211;9 locations in the fundus&#44; and 3&#8211;4 in the antrum&#44; with specific loose stitches&#46; Supposedly&#44; the resulting plicature using these new techniques leads to greater gastric reduction and at the same time produces a slowdown of gastric emptying&#44; helping to produce a satiating effect&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Objective</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the cases of 2 patients&#44; on whom the Apollo technique was used and who&#44; after one year of follow-up and failure of quantifiable results&#44; sought a surgical solution&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical cases</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">A male patient aged 37&#44; with a body mass index &#40;BMI&#41; of 42<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> and obstructive sleep apnoea syndrome&#44; on whom 7 months previously the Apollo technique had been used for gastric reduction&#44; without incident&#46; The patient presented with a quantifiable weight gain of 9<span class="elsevierStyleHsp" style=""></span>kg during the following 7 months and therefore attended our surgery in search of a solution&#46; After a complete study by our multidisciplinary team&#44; which included a gastroduodenal radiologic study that reported him as having a &#8220;normal stomach&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; laparoscopic sleeve gastrectomy surgery was performed on the patient&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Case 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">A female patient aged 33&#44; with a BMI of 45 and no comorbidities&#44; into whom 30 months previously an intragastric balloon &#40;for 6 months&#41; had been inserted but without any outcome&#46; After this &#40;13 months later&#41; the Apollo technique for gastric reduction was practised&#46; One year after this technique&#44; the patient was 14<span class="elsevierStyleHsp" style=""></span>kg heavier than the day of the operation and she therefore attended our surgery to be treated for her obesity&#46; Following a complete multidisciplinary study&#44; which included a gastroduodenal radiologic study that reported her as having a &#8220;normal stomach&#8221; laparoscopic sleeve gastrectomy surgery was scheduled&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">During surgery on both patients adhesions to the parietal peritoneum&#44; liver&#44; and the pancreatic body were observed&#46; These were released to continue the surgical procedure&#46; During the dissection of increased curvature&#44; there was some digitation which corresponded to the endoscopic suture&#44; but no plicature or torsion imaging was observed&#44; with the exception of the above-mentioned adhesions and several areas of thickening &#40;the above-mentioned digitation mainly referred to in the antrum&#41;&#46; The impression was that of finding a practically normal stomach&#46; Surgery was performed by completing dissection to the angle of His and performing the gastrectomy with staples&#44; reinforced with 2&#46;0 barbed sutures&#46; There were no difficulties during the operations that differed from a patient who had not previously had gastric surgery&#46; Examination of the extracted specimen revealed several slightly folded areas &#40;in fundus and antrum&#41;&#44; with no obvious reduction of gastric capacity &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The patients were discharged from hospital 36<span class="elsevierStyleHsp" style=""></span>h after surgery without incident&#46; During follow-up the patients lost weight at a normal post-bariatric surgery rate without any presence of complications&#46; After one year of follow-up the percentage of excess BMI lost was 62&#37; and 73&#37; respectively&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The development of new endoscopic techniques and improvements in the designs of existing ones has meant that during recent years&#44; the procedures using this route have attempted to replace surgery for some patients with obesity when medical treatment fails&#46; Rejection of surgery or contraindications&#44; excessive risk or the presurgical period to reduce morbidity in surgery may be some of the situations where these systems would be indicated&#46; The suture systems &#40;POSE&#44; TOGa&#44; Apollo&#44; etc&#46;&#41; form a considerable number of endoscopic techniques which during recent years have reproduced the manipulations and physiological effects minimally invasive surgery has on the treatment of morbid obesity&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a> They try to reduce the stomach&#39;s ability to store food&#44; thus inducing early satiety&#44; and delay gastric emptying by applying folds in the stomach wall&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Until now&#44; only one study has been published by Espin&#243;s et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> which included 45 obese patients with a mean BMI of 36&#46;7&#44; where the follow-up was a mere 6 months&#46; They present a reduction of BMI of 5&#46;8 &#40;31&#46;3&#41; and a SPSS of 49&#46;4&#37;&#46; They conclude that the POSE appears to be a safe and effective procedure with regards to weight loss&#44; no pain&#44; scarring and recovery from surgery&#46; Vilallonga et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> in their response to the before-mentioned article&#44; are aware of the scarcity of publications which appear to defend the efficacy of fundus plicature or even gastric antrum plicature&#44; which supposedly activates satiety receptors or slows down gastric emptying&#46; They believe that the mechanisms relating to satiety&#44; motility or even gastric volume are complex and cannot simply be explained by an unquantifiable reduction of the gastric fundus&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">L&#243;pez-Nava et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> recently published their results in a series of 20 patients with a follow-up of 6 months after endoscopic sleeve gastroplasty&#46; They report a preoperative and follow-up BMI of 35&#46;6 and 31&#46;9<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; respectively&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Deitel and Greeinstein<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> propose the use of the lost BMI percentage to evaluate results&#44; so much so that they consider it an excellent result if there is over 65&#37;&#44; a good result if it is between 50&#37; and 65&#37; and a failure when it is below 50&#37;&#46; None of the studies mentioned use this formula to assess outcome&#46; Furthermore conclusions cannot be reached with such small cohorts and a follow-up of only 6 months&#46; Randomised&#44; controlled and well-designed studies are needed to determine the efficacy and safety both in the short and long term&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">As studies on laparoscopic sleeve gastrectomy have been published which report a slight swelling of the gastric tube one year after surgery&#44; so too should studies be carried out to show what the outcome of gastric plicature with the endoscopic techniques would be in the mid to long term&#44; either through further endoscopies or with barium transit tests&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The increased pressure maintained over the gastric tube could lead to failure of the technique through the opening of the sutures&#44; without the patient showing any signs of complications&#46; This was such in the presented cases as both patients practically presented with an opening the length of the gastroplasty suture&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">It is possible that we will increasingly find more patients for whom treatment of this type has failed and they will come looking for a definitive solution to their weight loss&#46; As we have shown with these two cases&#44; laparoscopic sleeve gastroplasty after the failure of an endoscopic technique does not offer great variation from the standard technique&#46; However&#44; we would recommend a careful&#44; meticulous technique since the percentage of complications could rise in these patients&#44; similarly to revision surgery&#46; Adhesions should therefore be released to maintain normal gastric anatomy&#44; and fibrous&#44; swollen areas should be located to avoid sectioning in this region&#44; as much as possible&#46; Although it has not been demonstrated that the risk of fistulas is reduced&#44; we would recommend enhancement with suturing in the section line in this type of patient&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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            0 => "T&#233;cnicas endosc&#243;picas"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Attempts are being made in recent years to replace open surgery with endoscopic techniques in some obese patients when medical treatment fails&#44; as they are considered to be less-invasive procedures&#46; To date&#44; there is little scientific evidence regarding their effectiveness&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical cases</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The cases are reported of 2 patients who attended our surgery looking for an effective bariatric surgical treatment after failed endoscopic sleeve gastroplasty&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic sleeve gastrectomy after failure of an endoscopic technique does not offer great variation from the standard technique&#46;</p></span>"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Antecedentes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Durante los &#250;ltimos a&#241;os&#44; las t&#233;cnicas endosc&#243;picas intentan sustituir a la cirug&#237;a en algunos pacientes con obesidad&#44; cuando el tratamiento m&#233;dico fracasa&#44; bas&#225;ndose en que son t&#233;cnicas menos agresivas&#46; Hasta la fecha&#44; existe muy poca evidencia cient&#237;fica de su efectividad&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Casos cl&#237;nicos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentamos 2 casos de pacientes intervenidos mediante gastroplastia vertical endosc&#243;pica que&#44; tras su fracaso&#44; acuden en busca de un tratamiento quir&#250;rgico bari&#225;trico efectivo&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La gastrectom&#237;a vertical laparosc&#243;pica tras el fracaso de una t&#233;cnica endosc&#243;pica no supone una gran variaci&#243;n sobre la t&#233;cnica est&#225;ndar&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ferrer-M&#225;rquez M&#44; Ferrer-Ayza M&#44; Rubio-Gil F&#44; Torrente-S&#225;nchez MJ&#44; Mart&#237;nez Amo-G&#225;mez A&#46; Revisi&#243;n quir&#250;rgica bari&#225;trica tras gastroplastia vertical endosc&#243;pica&#46; Cir Cir&#46; 2017&#59;85&#58;428&#8211;431&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Esophageal and gastroduodenal transit&#46; <span class="elsevierStyleItalic">Case 1</span>&#58; regular stomach walls&#44; with no excess images&#44; defect or extrinsic compressions&#59; no signs of reflux or hiatus hernia&#46; Emptying without incident&#46; <span class="elsevierStyleItalic">Case 2</span>&#58; regular stomach walls&#44; with no excess images&#44; defect or extrinsic compressions&#59; no signs of gastroduodenal reflux or hiatus hernia&#46;</p>"
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ISSN: 24440507
Original language: English
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