chana

You should know that one of the perforations due to gastric necrosis happened to one of my patients. I have since contacted many bariatric surgeons to inform them of this and in doing so learned that there have been several other cases in other clinics as well, some of whom had their surgery outside the U.S. As soon as I learned this I posted the information on this forum as well as our plication patient's private message board.
Will I continue to recommend plication surgery? The short answer is not right now. Regarding full length plication as a primary operation I think we need more information on why some patients are developing gastric necrosis and some are not. We've had many successful plication patients with excellent weight loss. Certainly perforation is a known potential complication of stapled sleeve gastrectomy as well, but considering that relatively small numbers of plications are being performed around the world, a few perforations is too high of an incidence for me especially given the magnitude of the complication. When a perforation occurs in a plication, this stomach has to be removed, the end result of which is essentially a stapled sleeve gastrectomy.
One of the things that attracted me to the plication is that it seemed like it would avoid the possibility of perforation since there were no staple lines. These perforations are occuring through a different mechanism - compromised blood flow to the stomach. In speaking with many bariatric surgeons in the U.S. we would not have anticipated this based on our knowledge of the stomach's blood supply. We do not think this is an arterial problem (inflow of blood) - it seems to be a problem of venous congestion or impairment of venous drainage in the crowded stomach. In simple terms, if the venous blood can't flow out of the tissue, this ultimately impairs the arterial inflow of blood from coming into the tissues. The end result is necrosis of the tissue which can perforate. This is the best theory we have currently on why this has occurred.
It is possible that a much looser plication or a single row plication instead of two rows might prevent this from occurring but would likely also reduce average weight loss success. An early study in a small number of patients at the Cleveland Clinic showed that anterior plication (only plicating the front part of the stomach) had disappointing weight loss results and they subsequently abandoned the technique. It is likely that tighter plications have better weight loss but higher risk for perforation and a looser plication might reduce the chance for perforation but also reduce weight loss success.
We have not had the experience that necrosis shows up later in the post-operative course. If you currently have a plication consult or surgery scheduled I would recommend that you discuss this with your surgeon. If I learn additional important information I will post it on this forum.