Jason L. Harris

Laparoscopic gastric plication for treatment of severe obesity.

BACKGROUND Current gastric restrictive procedures include either a prosthetic device or gastric resection. We present the results of a feasibility study using laparoscopic gastric plication for weight loss achieved without stapling or banding. METHODS After institutional review board approval, 2 methods were used to achieve laparoscopic gastric volume reduction. In the first group (anterior plication [AP]), the anterior gastric wall was folded inward from the fundus to the antrum using 2 rows of running sutures. The greater and lesser curvatures were approximated to create an intraluminal fold of the stomach. In the second group (greater curvature plication [GCP]), the short gastric vessels were divided, and the greater curvature was folded inward, with 2 suture lines to reduce the gastric capacity by a large intraluminal gastric fold. RESULTS The average preoperative body mass index was 43.3 kg/m(2) (range 36.9-49.0), and 3 patients were men. Of the 15 patients, 9 underwent AP. For the 9 patients who underwent AP, the 6- and 12-month endoscopic evaluations demonstrated comparable-size plications over time, except for in 1 patient, who had a partially disrupted fold. Of the 6 patients who underwent GCP, the 6- and 12-month follow-up endoscopic examinations demonstrated a durable intraluminal fold, except for in 1 patient, with a partial disruption at the distal fold owing to a broken suture. For patients completing 1 year of follow-up, the percentage of excess weight loss was 23.3% ± 24.8% in the AP group (n = 5) and 53.4% ± 22.7% in the GCP group (n = 6). No bleeding or infectious complications developed. The first patient in the GCP group required reoperation and plication reduction owing to gastric obstruction. CONCLUSION Our initial experience has suggested that a reduction in gastric capacity can be achieved by way of plication of the anterior stomach and greater curvature. The early weight loss results have been encouraging, with better weight loss in patients who underwent GCP. The use of laparoscopic GCP warrants additional investigation as a primary bariatric procedure.

Gastric plication: preclinical study of durability of serosa-to-serosa apposition

BACKGROUND Vertical gastric plication is a novel surgical approach for reducing the stomach capacity. Anterior surface plication and greater curvature plication are variations of vertical gastric plication that reduce the gastric capacity through infolding of the anterior surface or greater curvature of the stomach, respectively. These approaches have been tested, with positive results in a small number of preclinical and clinical trials. A key step toward greater investigation of vertical gastric plication as a viable bariatric procedure would be confirmation that the apposed serosal tissues can be securely and durably bonded. We compared the short-term durability of gastric plications and serosal bonds using a variety of fastening devices and techniques in a university hospital and private company setting. METHODS A total of 30 anterior surface plication and 8 greater curvature plication procedures were performed using an open or a laparoscopic surgical technique in 38 hound dogs. The fastening devices used were T-tags, buttressed T-tags, 2 types of suture, and 4 types of staple-based fasteners. The density of the fastening devices was varied among the dogs. With 3 exceptions (2 in keeping with the study design and 1 due to complications), the dogs were followed up for 8 weeks. Histologic examinations and tensile testing were performed postmortem. RESULTS All fastening devices created durable plication folds, except for 1 technique. The only technique that did not produce durable serosa-to-serosa adhesions was a staple/suture combination. Intentional abrasion of the apposed sites had no demonstrable effect on the bonds between the tissues in any group. Increasing the fastener density and number of rows increased the adhesions within the folds. CONCLUSION Our findings have confirmed the short-term durability and development of dense fibrous appositions of the serosal folds for fastening approaches that create fixed serosal apposition. Additional studies are needed to identify the optimal fastening modality for anterior surface plication, greater curvature plication, and, ultimately, clinical applications of this procedure.

Ex Vivo Modeling of Perioperative Air Leaks in Porcine Lungs

Objective: A novel ex vivo model is described to advance the understanding of prolonged air leaks, one of the most common postoperative complications following thoracic resection procedures. Methods: As an alternative to in vivo testing, an ex vivo model simulating the various physiologic environments experienced by an isolated lung during the perioperative period was designed and built. Isolated porcine lungs were perfused and ventilated during open chest and closed chest simulations, mimicking intra and postoperative ventilation conditions. To assess and validate system capabilities, nine porcine lungs were tested by creating a standardized injury to create an approximately 250 cc/min air leak. Air leak rates, physiologic ventilation, and perfusion parameters were continuously monitored, while gas transfer analysis was performed on selected lungs. Segmental ventilation was monitored using electrical impedance tomography. Results: The evaluated lungs produced flow–volume and pressure–volume loops that approximated standard clinical representations under positive (mechanical) and negative (physiological) pressure ventilation modalities. Leak rate was averaged across the ventilation phases, and sharp increases in leak rate were observed between positive and negative pressure phases, suggesting that differences or changes in ventilation mechanics may strongly influence leak development. Conclusion: The successful design and validation of a novel ex vivo lung model was achieved. Model output paralleled clinical observations. Pressure modality may also play a significant role in air leak severity. Significance: This work provides a foundation for future studies aimed at increasing the understanding of air leaks to better inform means of mitigating the risk of air leaks under clinically relevant conditions.