Comparison between butterfly gastroplasty (a new modified gastroplasty technique) and sleeve gastrectomy

Comparison between butterfly gastroplasty (a new modified gastroplasty technique) and sleeve gastrectomy

ElsobkyAS.,  MD; MashaalAnas., MD; MohammedMahfous  MD; Marzouk M.A., MD; Youhanna S. Shafik, MD, MRCS, Eng; Sherif Abdelhalim, MD

Department of General Surgery, Ain Shams University, Cairo, Egypt.

Background: Vertical banded gastroplasty  (VBG) and sleeve gastrectomy(SG)  are purely gastric restrictive procedures designed to reduce appetite by decreasing the size of the stomach. Butterfly gastroplasty, is a modification of (VBG) in which a micro funnel shaped pouch was constructed limited to cardia in order to reduce the risk oflong-term staple-line disruption. This study presents preliminary results of our early experience with both procedures.

Methods: From August 2010 till August 2012 (60) consecutive patients with morbid obesity (9 males and 51 females) divided into two groups, (group 1) underwent laparoscopic butterfly gastroplasty  (30  patients)  and  (group  2)  underwent  laparoscopic  sleeve  gastrectomy  (30 patients).  This study aimed to compare the preliminary results  of both procedures including operative  morbidity and mortality,  short and long-term  complications,  as well as follow-up rates and parameters of weight loss.

Results:  There were 6/30 (20%) and 3/30 (10%) cases with intra-abdominal  bleeding in butterfly  gastroplasty  and  sleeve  gastrectomy  groups  respectively.  In  butterfly gastroplasty group, one (1130)  early  complication  (3.3%)  was encountered,  late complications  occurred in one (1130) patient (3.3%) with no mortality occurred; two patients had persistant vomiting. In  sleeve gastrectomy  group,  two (2130) early  complications  (6.7%)  (leakage  arising  from stable line of the stomach) were encountered with no late complications or mortality occurred. Substantial  weight loss occurred in all patients. For butterfly gastroplasty group mean excess weight loss (EWL %) was 41.99±6.17  % at 6 month and 64.02±5.16% at 1 year, while for sleeve gastrectomy EWL% was 41.12±3.7 % at 6 month and 53.85±5.44% at 1 year. The rate of complete resolution of co-morbidities  in butterfly gastroplasty was 100% for hypertension at 6 month and diabetes mellitus at 12 month, while in sleeve gastrectomy group resolution of hypertension was 90.9% and diabetes mellitus was 92.6% at 12 month

Conclusion: Butterfly gastroplasty and sleeve gastrectomy are feasible and safe restrictive bariatric procedures, with good short-term results and low morbidity rates. In comparison to sleeve gastrectomy, Butterfly gastroplasty has higher intra-operative complication  rate (in the form ofbleeding), however it has also higher percentage of postoperative excess weight loss as well as reduction of assoiated preoperative morbidities.

Introduction:

Bariatric  surgery is the most effective treatment for long-term reduction of body weight. Bariatric surgery should at least be considered for all patients with a BMI of more than  40  kgf m2 and for those  patients  with  a BMI of more  than  35 kg!m2 with  important

obesity     related     co-morbid     conditions. 1

There  are  two  major  categories  of  weight­ loss   surgery:    gastric    restriction   such   as vertical  banded  gastroplasty (VBG),  gastric banding, sleeve  gastrectomy and intestinal malabsorption which  include  Roux-en-Y gastric     bypass     (RYGB),     biliopancreatic

diversion   (BPD). 2   The  sleeve   gastrectomy

(SG)  is a  restrictive procedure that  creates

Am-Shams] Surg 2014; 7(19):1-10

a 100- to 150-mL stomach by performing a partial  gastrectomy  of the  greater  curvature side of the stomach. The last 6 to 8 em of antrum remains intact, and thus, the pylorus is preserved to help prevent gastric emptying problems.3 The vertical banded gastroplasty (VBG) is a restrictive procedure that consists of   a   vertically   oriented   proximal   small pouch (less than 30 mL) that drains through a narrow  (10-12  mm)  gastric channel.  The outlet channel is reinforced with a band of polypropylene (Marlex) mesh.4 With VBG procedure the stapling ofthe stomach carries the risk of staple-line  disruption. In butterfly gastroplasty, a micro funnel shaped pouch was constructed limited to cardiaS this is assumed to reduce the incidence of complication rates after original VBG especially weight regains due to pouch dilatation and/or staple-line disruption.6 The aim of this study was to investigate  and evaluate rate of weight  loss and amelioration of obesity co-morbidities as well as the intra-operative  and postoperative complications for the two bariatric procedures (Laparoscopic butterfly gastroplasty and Laparoscopic      sleeve     gastrectomy)     for two years post-surgery at the Ain Shams University Hospital (El-Demerdash), Ain Shams Specialized Hospital,  and Ahmed Maher Hospital.

Methods:

From   August   2010   till   August   2012 (61) consecutive patients (9 males and 52 females)   underwent   restrictive   procedures for their morbid obesity. They were divided into two groups, (group 1) with laparoscopic butterfly gastroplasty (31 patients) and (group

2)   with   laparoscopic   sleeve   gastrectomy

(30  patients).  One patient  of group  (1) was converted to open procedure due to bleeding from one of short gastric vessels, splenectomy and standard VBG was done. So this patient was excluded from this study. The net result that  we  had two  groups  of  patients,  group (1)  with  laparoscopic  butterfly  gastroplasty (30   patients   =50%)    and  group   (2)   with laparoscopic  sleeve gastrectomy (30 patients

= 50%).  All the  patients  met the  inclusion/

exclusion   criteria   followed   the   by   INH

Bariatric guidelines. 7 More than 18 years old, BMI >35 with diabetes or other important co­ morbidities, no alcohol abuse or concurrent psychiatric illness. With the exclusion  of all patients who were sweet eaters and patients who had upper abdominal or revisional surgeries. Ideal body weight was determined according to the Metropolitan Life Insurance height/weight tablesJ A comprehensive, multidisciplinary, bariatric management program was tailored for the preoperative preparation  and  postoperative   management of patients. The program included support groups and ancillary personnel to provide nutritional, exercise, and psychological care). Data sources included office charts, hospital charts, follow-up notes, telephone calls, and e-mail messages.

Preoperative evaluation: The preoperative

evaluation is almost the same for both procedures.  The  risks,  benefits,  and  long­ term consequences of both procedures were discussed in detail during the initial encounter with the surgeon and the dietician. Written informed   consent   was   obtained   from   all patients before being assigned to surgery. An extensive preoperative evaluation including history, physical examination, and indicated specialty  consultations  was  performed. Routine laboratory evaluation was done. All patients received preoperative  low molecular weight  heparin  and  antibiotic  prophylaxis, and  IV  proton  pump  inhibitors  two  hours before surgery.

Operative technique:

Laparoscopic      butterfly      gastroplasty: The position of the patient and trocars are similar to any hiatal procedures. Anterior and posterior layers of the gastro-splenic ligament are divided from the level of splenic vessels up to the angle of Hiss. The first articulating endo  cutter  (blue  45)  is  applied  from  the angle of Hiss downward with complete exclusion  of gastric fundus.  At the  level of the first branch of left gastric artery, retro­ gastric spaces were completely dissected and the  second  endo  cutter  cartridge  (blue  34) was applied to perform the butterfly shaped pouch with accurate adjustment ofthe pouch

Figure (1): Diagram show sleeve gastrectomy procedure

Figure (2): Butterfly gastroplasty 1) Opening first layer of gastro-splenic lig. 2) Opening second layer of gastro-splenic lig. 3) Opening in lesser omentum at level of Lt. gastric artery.

4) Applied first endo-cutter. 5) Applied second endo-cutter. 6) Funnel shaped pouch at cardia.

outlet (1.2crn). The outlet of the pouch was banded with a proline mesh (4 x1.5 ern). An ornentoplasty was always performed using omentum to cover the mesh. Naso-gast:Iic tube and abdominal drainage were left in place.

Laparoscopic sleeve gast:I·ectorny: Surgical Technique  LSG  was  perfonned  according to the technique described by Gagner.2 The division  of  the gast:Iic greater  curvature vascular supply, starting at 7-8 ern fi:orn the pylorus  and  proceeding upwards  until the

Figure {3a): {1-2): The division of the gastric greater curvature vascular supply, starting at

7-8 em from the pylorus.

Figure (3b): (1-2): The LSG is created using a linear stapler (Endo GIA).

Butterfly Gastroplasty

cMate   cFemale  I

Sleeve Gastrectomy

26.7%

Figure (4): Gender among the studied groups

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Figure (5): Comparison between the studied groups regarding to age, weight, BMI and mean excess weight.

Figure  {6): Associated  Co-morbidities  for both groups.

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Figure (7): Staple-line leakage after LSG, treated with percutaneous drainage.

angle of His, was canied out with Harmonic Scalpe,  (Ethicon).The   LSG   was   created using a linear stapler Endo GIA, with two

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Figure   (8):  Postoperative  BMI  for  both groups for 2 years.

sequential 60-mm green load filings for the annum, followed by two or tluee sequential

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Figure   (9):  Postoperative   percentage     of weight loss for both groups for 2 years.

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Figure  (10):   Postoperative  Excess  weight

Joss for both groups for 2 years.

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rronths months rrmths rrpnths rrmths rrpnths

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months    months   months

Figure (11): Postoperative EWL and BMI after Butterfly Gastroplasty group for 2 years.

EWL                                                                                               BMI

70 -

60                                                                                                  70

50                                                                                                   60

40                                                                                                  60

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Baseline       3           6           9               12              18         24                     Baseline       3                6                9                12          18             24

months  months  months  months  months months                             months   months  months   months  months  months

Figure (12): Postoperative EWL and BMI after Sleeve Gastroplasty group

IoButterfly Gastroptasty group oSleeve Gastroplasty groupI

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Hypertension             Diabetes mellitus

Hypertension            Diabetes mellitus

Figure

(14):    Amelioration

of     the    co-

Figure    {13):   Amelioration     of     the morbidities after 1 year.

co-

morbidities after 2 years.

Table (1): Demographic distribution  ofpatients undenvent butterfly gastroplasty and sleeve gastrectomy.

Value expressed as Mean ±SD (range)

Table (2): Associated co-morbidities  for both groups .

Table (3): Intra-operative complications for both procedures:

corpus and fundus. The stapler was applied alongside a 48 Fr calibrating bougie strictly positioned against the lesser curve, to obtain a 120-150 ml gastric pouch. The resected stomach  is extracted  by enlargement  of the

15-mm port-site up to 25 mm opening. Nasa­

gastric tube and abdominal drainage were left in place.

Postoperative care:

All the patients were monitored in the recovery room and were transferred to the wards or to the intensive care unit. Early postoperative ambulation was strongly encouraged   with   patients   getting   out   of bed the evening  of the surgery and walking by the first postoperative day. In butterfly gastroplasty a clear liquid diet was started on

Table (4): Post-operative  complications  for both procedures:

1st postoperative day, was advanced to pureed food  2 weeks later, and to solid food by the

4th postoperative  week,  however  in sleeve gastrectomy  upper  gastrointestinal   contrast (Gastrografin study was routinely performed on the second postoperative day, followed by at discharge, the same dietary instructions as mentioned  before.  Patients  were  advised  to take  daily  multivitamins  and  supplemental minerals,  as well as  proton  pump  inhibitor (PPI)  prophylaxis   for  6  months.  Follow­ up  appointments  with  the  surgeon  and  the dietitian  were scheduled  at 2nd weak,  1, 3,

6, and 12 months postoperatively, then twice a year.

Endpoints:

The  pnmary  endpoints  included comparison   between   butterfly   gastroplasty and    sleeve    gastrectomy    procedures    as regard  the  operative   mortality  (within  30 days of surgery), short-term complications (complications     that    prolonged     hospital stay and/or necessitated invasive treatment before 30 days of surgery), and long-term complications (occurring after 30 days of surgery). In addition, we analyzed the follow­ up  rates  and  parameters  of  weight  at  each time point for both procedures as well as the

effect on associated co-morbidities.

Results:

Demographic  distribution  of the  patients is summarized  in  Table (1), the  mean  age was   32.13±9.06   years,   average   (18-49y) and 32.04±7.59 years, average (21-44y) for butterfly gastroplasty and sleeve gastrectomy groups respectively. The mean pre-operative body mass index was 55.96±7.75 kg/m2, average   (41.6-71.3)    and   55.82±9.74   kg/ m2, average (37.8-70.2), and the mean pre­ operative  weight  was  148.78±25.76  kg, average (108-200kg) and 140.17±30.44 kg, average (98-207kg) for both groups.

Clinical data and associated obesity co­ morbidities are illustrated in Table (2), 21/30 patients  (70%)  and  23/30  patients  (73.3%) had  hypertension   in  butterfly  gastroplasty and sleeve gastrectomy groups respectively, diabetes    mellitus    in   24/30    (80%)    and

27/30  (90%),  and  degenerative  arthritis  in

4/30  (13.3%)  and  1130 (3.3%)  in  butterfly gastroplasty and sleeve gastrectomy groups respectively.  Only  5  patients  (16.7%)  had sleep apnea in sleeve gastrectomy group.

Outcome:

The incidence of intra-operative complications    is   presented   in   Table (3).

There was higher incidence of intra-operative

Am-Shams] Surg 2014; 7(19):1-10

Table  (5):  Weight  loss  parameters   for  2  years  after  butterfly   gastroplasty   and  sleeve gastrectomy.

complications in the form of intra-abdominal bleeding 6/30 (20%) in butterfly gastroplasty than  patients  with  sleeve  gastrectomy  3/30 (10%), (Significant). In butterfly gastroplasty group,  bleeding  in  two   patients  was   due to  injury  of  one  of  short  gastric  vessels. The  other  four  patients  (13.3%)  presented

by tear  in  liver  tissue  with  variable  depth

mostly  caused  by  liver  retractor.  In  sleeve gastrectomy  group,  one  patient  (3.3%)  had intra-operative  bleeding  from  vessels  along greater  curvature  of  the  stomach,  and  the other two patients (6.7%) had injury in liver tissue by means of liver retractor. In all cases bleeding   was   controlled,   with   inventible

postoperative course.

in-   ams     urg       ;

Table6: Amelioration of the co-morbidities  after 2 years in both groups.

The incidence of early and late post­ operative   complications   was  illustrated   in Table (4).  In  butterfly  gastroplasty   (group

1), one (1/30) early complication (3.3%) was

encountered,  late complications  occurred  in one (1/30) patient (3.3%) with no mortality occurred; one patient had persistant vomiting in  1st post-operative  week,  proved  by contrast study (gastrografin  meal) to be due to pouch outlet obstruction, this patient  was re-operated  laparoscopically  and  proven  to be stomal  obstruction  by the  inserted  mesh at the stoma, and mesh re-position was done. The   other   one   developed   intolerance   to semi solid food 3 month postoperatively,  on contrast study stomal stenosis was diagnosed, endoscopic balloon dilatation was satisfactory to overcome this condition.

In sleeve  gastrectomy  group,  two  (2/30)

early complications (6.7%) were encountered with   no   late   complications   or  mortality occurred;  two  patients  had  leakage  arising from  stable  line  of  the  stomach,  the   1st developed   signs   of   acute   abdomen   with discharge  of  gastric  juice  per drain  on  the

4th postoperative day, this patient underwent open revisional surgery on 5th post-operative day, stable line was closed by means of interrupted  non  absorbable  sutures.  In contrast , in the other case with leakage, the patient was haemo-dynamically  stable, with low output per drains (200 cc amount I 24h)

The  condition  was  successfully  controlled

by conservative measures for 2 weeks which included broad spectrum antibiotics, total parental nutrition and percutaneous  drainage of     accumulated      intra-abdominal      fluid Figure (7).

Changes of mean BMI, weight, percentage

of weight loss, percentage excess weight loss are  shown  in  Table (5).  Substantial  weight loss occurred in all patients. For butterfly gastroplasty group mean excess weight loss (EWL %) was 64.02 ± 5.16% at 1 year and

66.93  ± 5.73%  at 2 years,  while for  sleeve gastrectomy    group   EWL   %   was   53.85

± 5.44% at 1 year and 57.41 ± 3.75 at 2 years. It can be seen that butterfly gastroplasty was better  than  sleeve  gastrectomy  in terms  of mean excess weight loss and this difference is significant (P < 0.05) through 2 years. The rate of complete resolution of co-morbidities in butterfly gastroplasty was  100% for hypertension at 1 year and diabetes mellitus at  2  years,   while   in  sleeve   gastrectomy group resolution  of hypertension was 90.9% and diabetes mellitus was 92.6 % at 2 years postoperatively  Table (6).

Discussion:

It is  generally  accepted  that there  is  no ideal bariatric operation and that the bariatric surgeon should choose the most appropriate procedure  for each  individual  patient  based on specific selection criteria by creating a flexible   treatment    algorithm.7     Restrictive

Am-Shams] Surg 2014; 7(19):1-10

procedures   are   generally   considered   safe and quick to perform, and usually lead to satisfactory  short-term  weight  loss  results.8

LSG originally proved to be a beneficial procedure for interval weight loss as the first stage   of  a  two-staged   bypass  procedure.3

More recently, LSG is showing promise as a primary bariatric procedure for appropriate candidates.9 Vertical banded gastroplasty (VBG) is an excellent weight loss option for people who are morbidly obese. In fact, this procedure is one of the first successful types of  weight  loss surgery for  people  who fall into this category.

VBG  staple   line  breakdown   has  been

reported to occur in almost 50% of patients. Dehiscence of the vertical stapled partition eliminates the restrictive nature of the surgery, leading to ingestion of larger portions and subsequent weight gain. Our new restrictive technique the butterfly gastroplasty, first described by Abdel Galil et al,5 is a modified VBG, it depends on creation of micro pouch limited to the cardia of the stomach in order to avoid the cardinal complications of the vertical  banded  gastroplasty  (VBG).   VBG is blamed of being responsible for that 35% of patients who underwent this procedure regained weight after five years.lO

Patients who underwent VBG usually present with intolerance of solids or persistent vomiting. This occurs in up to 40% of VBG patients. 11 While the incidence of vomiting in this study is 3.3% for the butterfly technique and thaf s related to the funnel shape of its pouch.

The reported incidence of staple line dehiscence   after  LSG  ranges  from  0%  to

5.5% and with overall complication rates ranging from 0% to 24%.12 In this study, the incidence of staple line dehiscence after LSG was (6.7%), while no case with such problem occurred  in the butterfly  group. It has been evident that in LSG a subgroup of patients do regain weight after the year, and the authors speculate that this proportion will rise with a longer follow-up.  Dilatation may be the first cause  of failure.l3  It may be a result of an excessively  large pouch being created at the

initial operation because of missed posterior

gastric    folds. 14    Baltasar    and   colleagues reported excess body weight loss (EWL) of

56% (4-27 months  after LSG) in the super obese   group.l2   Ifs  proved   in  this   study during  follow  up  for  2  year  post-operative that the butterfly gastroplasty  achieved mean excess weight loss (64%) more than that for LSG (54%). In addition the rate of complete resolution   of  co-morbidities   (hypertension and diabetes mellitus) was higher in butterfly gastroplasty  than  sleeve  gastrectomy  group for 2 years follow  up.  In Korean  study, the excess  weight loss from sleeve  gastrectomy was 71.6% at 6 months and 83.3% at 1 year, when defining the success of surgery in Korea, the patient's  postoperative dietary habits and long-term   follow-up   visits  play  important roles in weight loss. Koreans consume mainly carbohydrates  and less protein and fat, tend to dine under pressure due to Confucianism, which leads to fast eating, and the meal (appetizer, main course, drinks) is served  at once on one table, not in courses.l5

Wiener  et  al.  noted  that  LSG  is  not  a

simple   procedure,   and  owing  to  the  fact that the procedure is irreversible, surgeons should strive to avoid complications.l6 With butterfly   gastroplasty   using   of   only   two endo-cutter   cartridges   in  constructing   the funnel shaped pouch made it to a great extent easy  technique  with  less  costs  comparable to any other technique. In this study both butterfly gastroplasty and sleeve gastrectomy has the same percentage of post-operative complications (6.7%) but with more serious complication  for  sleeve  gastrectomy,  staple line leak, with percentage of 6.7% and none for the butterfly.

The VBG procedure does not appear to be

effective  in the treatment  of GERD.  In fact the VBG may accentuate  reflux possibly  by increasing intra gastric pressure and providing reservoir   (long  tubular   pouch)  for  reflux. It is  found  that  the  gastroplasty  increased the  prevalence  of  esophagitis   even  in  the presence  of  weight  loss.l3  One mechanism is  potential  decrease  in  acid  production  in the   gastric  pouch.  Anatomic  studies  have shown  that  the  cardia  of  the  stomach   is absent  of parietal  cells.  Rather they  can  be

Conclusion:

We  recommend  the   use   of  this   micro, funnel-shaped banded pouch using the gastric cardia only  (butterfly gastroplasty) as it is proposed theoretically to solve intraoperative technical problems , markedly reduces the costs  and  prevents the cardinal complications of the original VBG mainly weight regain, persistent vomiting, reflux disease and marginal   ulceration.   Follow  up   for    two years  confirmed particularly this theoretical concepts.

Reference

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158: 135-145.

2-    Blackburn   G,   Olbers  T,  Schneider  B,  et al: Surgical management of obesity and postoperative care. Nutrition and Metabolism

2009; 6: 329-345.

3-    Trelles  N, Gagner  M:  Sleeve  gastrectomy.

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4-          GagneD, DovecE,UrbandtJ, etal: Restrictive procedures: Laparoscopic revision of vertical banding to gastric bypass. Obesity Surgery Principles and Practice 2008; 33: 269-276.

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