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Abstract Vertical sleeve gastrectomy is a restrictive surgical technique that involves resection of a significant portion of the stomach by means of stapling the greater curvature. This procedure is rapidly gaining popularity and acceptance as a primary bariatric procedure with good results on weight loss. The other restrictive bariatric procedure is the adjustable gastric band. As the results on the vertical sleeve gastrectomy and the adjustable gastric band vary, there is still a gap that can be fulfilled by another procedure. The authors present an alternative procedure that is under investigation that can be as restrictive as sleeve gastrectomy with no staple line or prostheses. This procedure is called laparoscopic greater curvature plication, which is similar to vertical gastric banding, but without the need for gastric resection. The stomach is reduced by dissecting the greater omentum and short gastric vessels, as in vertical sleeve gastrectomy, then the greater curvature is invaginated using multiple rows of nonabsorbable suture over bougie to ensure a patent lumen. This article includes the background, method, initial results, and a brief discussion on this new procedure. Introduction Traditionally, the primary mechanisms through which bariatric surgery achieves its outcomes are believed to be the mechanical restriction of food intake, reduction in the absorption of ingested foods, or a combination of both.[1,2] Adjustable gastric banding (AGB) and vertical sleeve gastrectomy (VSG) are restrictive approaches commonly used in bariatric practice.[5,6] Although these procedures have proven to be good therapeutic options for some patients, they are not without significant complications, such as erosion or slippage of the gastric band or gastric leaks in VSG.[3,4,7,13,14] Leaks in VSG pose a particularly difficult challenge when they occur near the angle of His, potentially generating severe clinical conditions that require reoperation and may even cause death.[4] Since 2006, the authors have been evaluating the safety and initial results of the laparoscopic greater curvature plication (LGCP™), a restrictive bariatric surgical technique that has the potential to eliminate the complications associated with AGB and VSG by creating restriction without the use of an implant and without gastric resection and staple. Methods Using the National Institute of Health’s (NIH) inclusion criteria for bariatric surgery (patients with a body mass imdex >40kg/m[2] or BMI over 35kg/m[2] with at least one comorbidity), all patients underwent a multidisciplinary evaluation (endocrinologist, cardiologist, psychologist, and nutritionist), blood tests, abdominal ultrasonography, and upper endoscopy to establish baseline. The study design was a prospective, noncomparative case series that received approval from the local ethics committee with patients signing informed consent. From January 2007 to March 2010, 62 patients (44 female) were submitted to LGCP. Mean age was 33.5 years (ranging from 23 to 48 years) and mean BMI was 41kg/m2 (ranging from 35 to 46kg/m[2]). Technique Patients were placed under general anesthesia in supine positions. A Five-trocar port technique, similar to Nissen fundoplication, was used. Trocar placement was one 10mm trocar above and slightly to the right of the umbilicus for the 30-degree laparoscope; one 10mm trocar in the upper right quadrant (URQ); one 5mm trocar also in the URQ below the 10mm trocar at the axilary line; one 5mm trocar below the xiphoid appendices; and one 5mm trocar in the upper left quadrant (ULQ). The procedure began with angle of His dissection and removal of the fat pad, followed by careful dissection of the gastric greater curvature using the Harmonic™ scalpel (Ethicon Endo-Surgery, Inc., Cincinnati, Ohio), opening the greater omentum at the transition between the gastric antrum and gastric body. Once access to the posterior wall was achieved, the greater curvature vessels were dissected distally up to the pylorus and proximally up to the angle of His. Posterior gastric adhesions were also dissected to allow optimal freedom for creating a greater curvature flap. Gastric plication created by imbrication of the greater curvature over a 32-Fr bougie applying a first row of extramucosal interrupted stitches of 2-0 Ethibond™ (Ethicon, Inc. Somerville, New Jersey) sutures. This row guided two subsequent rows created with extramucosal running suture lines of 2-0 Prolene™ (Ethicon, Inc., Somerville, New Jersey). In the final aspect, the stomach was shaped like a sleeve gastrectomy but slightly larger. Leak tests were performed with methylene blue in all cases. No drains were left. Patients were discharged as soon as they accepted a liquid diet without vomiting. They also received a prescription of daily proton-pump inhibitor (PPI; single dose) for 60 days. Ondasentron and hyoscine (anti-spasmodic) were prescribed for seven days. The postoperative diet was a customized liquid diet for two weeks, with progressive return to solid foods in a stepwise fashion. Dietary restrictions were removed after 4 to 6 weeks, depending on patient adherence. Follow-up visits for the assessment of safety and weight loss were scheduled for 1 week and 1, 3, 6, 12, 18, and 24 months in the postoperative period. Endoscopic evaluations were scheduled for 1, 6, and 12 months postoperatively. Results All procedures were performed laparoscopically without conversions. Mean operative time was 55 minutes (40–110 minutes). Mean hospital stay was 36 hours (24 to 96 hours). On average, patients returned to normal activities seven days (4–13 days) following surgery. Mean percentage of excess weight loss (EWL) was calculated to be 20 percent at one month, 32 percent at three months, 48 percent at six months, 60 percent at 12 months, 62 percent at 18 months, and 61 percent at 24 months. No intraoperative complications were documented. All patients had lost at least 10 percent of total body weight. In the first postoperative week, however, nausea, vomiting, and sialorrhea in occurred in 22, 14, and 33 percent of patients, respectively. In all cases, these symptoms were resolved within two weeks. There has been no record of weight regain in any patient to date. Postoperative upper endoscopy and radiologic evaluation were performed on 12 patients at one and six months and in seven patients at up to 12 months. Qualitatively, the upper endoscopies suggest that the initial greater curvature fold is smaller at six months when compared with the initial fold size at one month, but appears unchanged at 12 months. Mild esophagitis (Grade A of Los Angeles classification) occurred in four patients at one month postoperatively; these patients were symptomatic (nausea, vomiting, and sialorrhea) and were kept on PPI, following the standard protocol. The six-month endoscopic evaluation identified no lesions or symptoms. Lumen size appeared stable (e.g., no dilation) based on upper gastrointestinal (GI) radiologic series performed on these patients at one and six months Discussion Reducing stomach capacity to promote mechanical restriction to food intake is one of the traditionally accepted mechanisms used in bariatric procedures to promote weight loss. There are at least two surgical procedures that appear to rely on this principle in current clinical practice, AGB and VSG. AGB achieves around 50 percent EWL, but unsatisfactory weight loss occurs in more than 20 percent of patients with failure rate requiring surgical revision in up to 25 percent of patients.[7] VSG as a primary bariatric procedure shows medium-term results to be adequate (>60% EWL), with improvements in comorbidities.[4,14] These promising results are associated with some complications, however, such as esophagites, stenosis, fistulas, and gastric leaks near the angle of His. These leaks and fistulas are reported in nearly one percent of cases and can be very difficult to treat.[4,14] LGCP is notably similar to a VSG in that it generates a gastric tube and eliminates the greater curvature, but does so without gastric resection. Initial clinical reports by Talebpour and Amoli[10] and Sales[11] demonstrate satisfactory weight loss up to three years. Brethauer et al12 reported increased weight loss in patients receiving LGCP when compared to plication of the anterior surface. The present series, compared to findings reported in some series involving AGB, has the lowest early complication rates among all bariatric procedures. Even with no major complications to report in the present series, Talebpour and Amoli[10] report one case of a gastric leak associated with a more aggressive version of LGCP, which they attributed to excessive vomiting in the early postoperative period. Adverse events described by patients were minor, lasting up to two weeks. These events may be related to the restriction induced by the invagination of the greater curvature and/or edema caused by venous stasis. Qualitative endoscopic findings suggest that the greater curvature fold gets smaller. This may be related with the resolution of the initial edema, although the radiological findings did not reveal significant dilation of the LGCP at six months. The percent EWL achieved a satisfactory 61 percent at 24 months in eight patients, with all patients achieving at least a 10-percent loss of initial weight. This can be favorably compared with results from VSG. This series is limited by the low number of patients, the simple study design, lack of a control group, the noninclusion of patients with BMI >50kg/m[2], and the incomplete follow-up period. This limits the broader acceptance of these results. These limitations limit the broader acceptance of these results. In order to better study this procedure, an international multicentric trial with centers in the United States, Chez Repuplic, and Brazil was designed (ClinicalTrials.gov Identifier NCT01077193). LGCP seems to be feasible, safe, and effective in the short term as a promising bariatric procedure on this initial series Acknowledgment Experimental evaluation was provided by Fusco et al8,9 that had published two articles about gastric plication on anterior wall and greater curvature of wistar rats achieving good results in weight loss analogy and significant better results of the greater curvature group. Recent clinical experience with variations of this technique has been described by few surgical groups. The authors’ initial experience was sent to the journal Obesity Surgery and was accepted for publication. More actualized data are described in this present paper. Original source can be fund here.

Hi Mercedes I'm Debbie from Pa. Having my surgery on the 25th of march also. Im On the 2 shakes and a supper also allowed a protein bar in there . . I'm also very hungry. I have had to put in A cheese stick low fat in there to help me out. Not easy I know . I have read many posts on here and it seems so many revisions from band to rny has been done. So I wouldn't think it would be my fault it didn't work. Just to many others out there that it didn't work for. I had the 3 month program to finish . I don't know if I'm making the right decision either. I have talked to others and they all felt the same way. I'm nervous also so your not alone. All I see is everyone says on here they made the right decision to have it done. They just would have done it sooner. I hope I'll be one of them and you to . Stay in touch with me ok

I'm being revised on May 18th! Would love to be your buddy!

My revision is May 21st..... happy to have a buddy! Lisa

People a lot younger than us get sleeve and bypass. It based on BMI and co-morbidities not age. I think he is a surgeon just not comfortable with sleeve but wants to keep your business. Get a second opinion. Most surgeons are moving away from band. Many of the sleeves done are lapband revisions because they are failing.

Sun Godess, As others have said complications occur even with the most qualified doctors. IMO, I would be more concerned with your heartburn issue and what this new doctor has to say about it. It is my understanding that heartburn can worsen with the sleeve if you already have it with the band. I was revised from band to sleeve and never knew what GERD was until now, which is another chance we take. I take Prilosec which is a PPI drug to control my heartburn and as you probably already know, there are concerns with long term use of PPI's. Just some things to discuss with him if you have not already done so. jake

Hello My friends! I had my lapband removal and sleeve revision done on Monday around noon. I have been home since yesterday afternoon and sadly am not one of you who has been pain free. I was hoping I was going to be pretty "ok" especially since I have a high pain tolerance, am younger and felt like I really prepared myself. I feel like absolute death! Sometimes it hurts to sip, hurts to breath, hurts to move, hurts to just be.... I know this will all pass, but I am just discouraged with the amount of pain I am in. I was sent home with liquid Hydrocodone and am allowed to take 10 ml every 6 hours... I have been using gas X pills as well. They seems to help (a little) when first taken, but definitely only about 1-2 hours long out of the 6 hour time frame. Hope everyone is well. Just focusing on getting myself better

My doctor will not do ESG on anyone who hasd previously had a gastric balloon as there is a high failure rate there, but do they know why the stitching had come apart? Did your surgeon do a bad ESG eg too loose stitching? Do you know how many ESGs they have done and what that surgeon's failure / revision rate is? I am a member of three facebook ESG groups and while there are people on there who haven't had success or much success there are so many more who have lost plenty of weight many longterm and maintaining. There are many reasons for failure just as VSG or RNY fail and until the reason is determined we can't say ESG (or even VSG and RNY) is a waste of money.

A lot of people understand just may not still be hanging around here when it gets to that point of removal etc... Those that do well don't always want to hear negatives and don't want to "jinx" their band situation. For those of us that don't do well or have complications it can be very frustrating because we want that same result. It doesn't mean we don't work as hard our bodies are just different. I just never was able to lose the weight and ended up gaining back what I lost before the surgery. It's hard to pin point exactly why but possibly with all my issues I just needed the malabsorption that other procedures have. I ended up being too tight and vomited too much and ended up with acid reflux which a lot of people get and even without any saline in the band was still having issues. So it was removed. I waited about six months before deciding to revise to another surgery, the RNY. My daughter had RNY a few months after I received my lap band and I've been with her through all the ups and downs but in the long run she's been successful. I got the lap band in 8/07, was put in the hospital for chest pains in 9/08 (acid reflux) and had it removed 10/08. The removal was covered by insurance and I'm in the waiting stages of approval for the revision to RNY 6/09. As far as I know it should be covered and am crossing my fingers and toes! Good luck to you Nancy.

I am a 44 yo registered nurse who is a Director of Quality in a small hospital in NWO. I have researched all my options. Orginally I wanted the VSG but now I really feel that the gastric plication is the tool I need to increase my chance of losing weight and keeping it off. I like that it is revisable and is not associated with malabsorption . I made my decision after two years of lurking on weight loss sites and trying various diets, personal training and pills. I would lose 15 and gain 20. I have watched my ability to snorkel and walk on vacation turn into shortness of breath and fatigue. I walk up the stairs to beat of 132 pulse. This has improved with cardio at the gym (120's ) I have beat myself up. Refused to go out with my husbands friends because they are thin and I am embarassed for my husband. Really I have spent my time making other people happy and not myself necessarily. Weight loss will not make me beautiful ( It is what is inside that counts). It will not make me successful as I feel that I am succesful professionally regardless of my weight. Weight loss will increase my energy and my overall health. My fears are complications related to the surgery. I am having my consultation appointment by phone with Dr. Brad Watkins from Cincinnati Weight Loss on Sept 7, 2011. I am 5 ft 3 inches and 216.5 today. This is a 38.4 BMI . So far I dont have high blood pressure or diabetes. I dont want them either. I will keep you posted:)

I don't know of anybody who has done that... probably because one could achieve the same thing by having the Fluid removed without the risk of surgery. I've sort of experienced life as a non-Bandster for a long-time... longer than I've been filled and Banded, actually. In my first 18 months of being Banded, I lost 95 pounds. Then I became pregnant.... three times! Each time I've tried to fill after the pregnancy, the Band hasn't worked the same. So I've had to be unfilled again. Up until the start of my third pregnancy, I had maintained a loss of 60-65 pounds of the 95. It's the first time in my life I've ever maintained any weight loss for more than a day. Seriously. I was not one of those people who lost 100 pounds and gained it back. I was the person who never loss more than 7 pounds to begin with... and always gained it back + 10. I just had my third baby... so we'll see how my final attempt at a refill goes in about 6 weeks. I can't imagine not having a tool to use... so I'm looking into a VSG should I need a revision. I really wish the Band worked as promised, however... as I really don't want to go through surgery again. It's such a different decision when one is single vs. when one has three little people to care for.

Yes there are 3! My insurance wanted me to use one of them b/c they are all "in network". Amy Elizabeth Martin Great Falls (406) 455-2821 More InfoRNY, LAP-BAND® Benefis Bariatric Institute 37Dale Mortenson Great Falls (406) 452-0877 More InfoRNY, LAP-BAND®, Revision Benefis Bariatric Institute 12David Rohrer Great Falls (406) 771-8411 More InfoRNY, LAP-BAND®, Revision Benefis Bariatric Institute 96

Good afternoon everyone! Just wanted to give an update. I got sleeved on 12/15/2011, I was a lapband to sleeve revision. I am loosing slowly but surely and I am currently at 152 lbs. I started with pre Lapband at almost 250 lbs and pre Sleeve at 193 lbs. I work out 3-5 times a week and I also drink my protein shakes as a meal replacement at least once a day and try to limit my carbs and sugars. It has taken a lot of work, but I am very proud of my accomplisments and very happy with myself at this point. A little nip and tuck wouldn't hurt but will look into that in the future!!

Hi and welcome! People experience slips for different reasons sometimes, it isn't known why a band slips, a patient can be compliant and it just happens. Other times it can be because someone is living with a too tight band, experiencing a lot of Productive Burping and regurgitating and the force of all of that can, in time cause a slip. Others, if a person, for whatever reason throws up a lot... That can cause a band to slip. A slip doesn't always result in loss of the band. A revision surgery can, in some cases set the band back in it's proper place and after a period of recovery and healing, the patient can get back on with their bandster life. In other cases, the band can't be set back in place and has to be removed or the patient chooses to have it removed and either revises to a different WLS or none, at all. Slipping is a possibility, but it isn't a given. It is a risk that you need to consider as you do your research and make your decision. Yes! It is absolutely okay to exercise with the band! You can do anything with the band that you can do without it.

YAY for you!! I had my revision 5/20/13. THE best decision I could have made after 6 yrs w/the band (4 of those yrs. dealing with complications). I am now a weight & size I've not seen in 20+ yrs. I tell people this is what I had hoped the band would do for me. I'm the "turtle"...slow ands ready will win the race. So, good luck and best wishes!

Mine didn't get serious till about 4 or 5 years later too. It got to the point that it was "uncontrollable" and no PPI worked. It wasn't till my throat was literally burning 24/7 that I decided I had to get it revised or I would be risking throat cancer.

Some people are very successful with the band, but knowing what I know now... the rate of failure, the rate of complications, slippage, rejection, etc and the difficulty most of my banded friends have with meat and other foods we're SUPPOSED to be favoring, I'd not have one. I also know a few folks who've had complications after the sleeve procedure, stricture, gallbladder, blood clots. The difference is, I don't know any sleeved person who's been damaged beyond repair after being sleeved. They've all recovered from their complications and would do it over again if given the choice. Unfortunately, I know a few folks who weren't so lucky with the band, having so much internal damage they needed revision to bypass or worse, or having continued problems after it was removed. It's true, the sleeve is an "irreversible" surgery. That is scary, but for me, lap band complications... much scarier and more frequent.

The same thing has happened to me. I was thinking about getting the revision surgery. I'd rather not go under the knife again. I know that you can do the diet from the first month to shrink your stomach again. Im m not sure how effective it is though.

I have Aetna POS in Texas as well. They will cover my band but will not cover the sleeve as my first WLS only as a revision. They tell me they consider the sleeve experimental. Who did you contact at Aetna? I am scheduled for Mexico on 12/29 and will lose my deposit and 1000.00 worth of plane tickets if I don't go there. I know that as soon as I get it done, Aetna will cover it. That is just going to be my luck. Bill

So...I have a lap band. I never got to the "green zone" or optimal restriction, just increased unbearable heartburn with additional fills. I have insurance, and kind of fell into the revision process this December. My insurance requires the repeat of the 6 mos diet process again to submit for a revision to sleeve. I do not want to wait and take the chance of ultimately being denied. So, I have scheduled a revision with Dr. Illan in a few weeks. Everything is all set up. I told my lap band surgeon a couple weeks ago at my last appt. He seemed concerned but understood. This morning I got a personal call from my lap band surgeon. He said his partner was in surgery as we spoke trying to fix a leak from a patient who had a sleeve done in Mexico. He said he was not trying to scare me, because he understands that I have to do what I have to do. He was just warning me that they see this regularly. He did not know the doctor or anything. So, I feel that I have done a good job, but am worrying now about the what if's due to it being a "revision" surgery of lap band to sleeve, and the possibility of a leak. It is scaring me now, and whether they REALLY REALLY REALLY check thoroughly before closing you up! I know they do leak tests during and after, but then how does someone get home and then have a leak!?!?! He did say, yes, it can happen to anybody. I am just wondering, scared and slightly second guessing. I can't afford to get back home and have complications and be in the hospital! I have found one band to sleeve patient on here who went to Dr. Illan. I have heard all glowing reviews. I have phone conferenced with Dr. Illan and feel good. I don't want fear to hold me back. I don't want to wait until July/August to hope to have surgery and maybe be denied because there "technically" is no mechanical error with my band. I am ready to move on and find success NOW beginning of April, be several pounds down by summer, all healed up, and moving on with my life...not to mention over this heartburn! Any words of wisdom and experience...especially of band to sleeve revisions would be greatly appreciated!

You will get varying answers but it has for me. I do feel "full" after eating 3-4 oz of food, particularly Protein. A lot of times I could go longer without eating but I eat so that I get enough calories for the day. (However I was not a revision).

I had a revision and with the band I was always hungry. I either had one of two extremes: too tight and everything slimed up or I could eat whatever I wanted (usually the second one). Now with the sleeve I have restriction. I can only eat a small amount and I get really really full. There are a few "slider" foods that I can eat more of like popcorn or chips, but I try to stay away from them as much as possible. I have found that I just don't obsess about food anymore. I do have a bit of hunger when it is time to eat, but once I get something in my stomach I am fine for hours. I LOVE my sleeve. I am losing weight (54 pounds in 4 1/2 months). The sleeve is a great tool!

I was not a revision either; but the doctor explained that when the stomach is removed so is the hormone that makes you feel hungry...I couldn't wait as I was previously ALWAYS hungry! It's true- I am not hungry, although I do have "head hunger" - times where I want something just because that used to be the habit. Some days I do not eat enough and I am positve that that is why I keep having plateaus and I am loosing slowly. But any loss is good loss, so I just try to be happy that it is going in the right direction. Good luck!

Thank you for responding...if you happen to find anything encouraging about revising from RNY to Distal RNY please let me know Sent from my SM-G920V using the BariatricPal App

HATED my band. Caused me so many issues. I am 1 month out from my revision to sleeve and I love it. It does everything for me that the band didn't. 3-5bites and Im done. I never had that with the band. It just made me throw up all the time.