After speaking with bariatric surgeons around the country I have learned about several reports of perforation due to gastric necrosis in patients that had plication surgery. These patients have presented within the first few days of surgery and complained of severe abdominal pain. To my knowledge, there are no reports of this presenting beyond the first few days after surgery. What is unclear is why this occurs in some patients and not others. The issue appears to involve impaired blood circulation in the crowded stomach tissue that has been folded in on itself. The cardia portion of the stomach (the upper part) seems to be susceptible to this. Since plication is a new procedure, at this stage it is important to know about this as a potential complication. I will continue to post updates on this forum as we learn new information.

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.

Hi. I am Dr Ali Fardoun, a bariatric surgeon working at emirates international hospital in al-ain uae . I read many comments about gastric plication. It is important to know that this procedure is done since 1957 and not new and the first one doing laparoscopically is Dr Talebpour from Tehran, iRAN since 11 years . Many surgeons in the world are doing and we had our first international meeting in Barcelona last 3rd of may 2011 with Dr Almino Ramos , Dr Ortiz , Dr Corvala, Dr Cottam, Dr Pujol , Dr Talebpour , and Me ( Dr Ali Fardoun ) and many others who are doing plication in the world . We did 5 live surgeries and discussed the most important aspects. I have contacted Dr Witkins but the secretary told that he can not come . I have been in the last gastric plication workshop on 22 oct 2011 in Cleveland with Dr Schuers's group and in the presence of many surgeons we discussed the subject. NOT ALL PLICATIONS ARE THE SAME. The technique has a standard now and our results are optimal. I had one leak due to thermal injury in the lower part of fundus near the attachement with the spleen in the posterior region and it was resolved in two months and treated as a sleeve leak. WE TREAT THE LEAK IN PLICATION OPENING THE SECOND ROW AND WILL BE RESOLVED IN FEW DAYS . I have done 70 cases in UAE in my hospital without any leak and the one I had was due to the work outside my hospital in Lebanon where i was not using my assistants and instruments. I learnt to do the plication in a new technique which is safe and easy and the weight loss is excellent 62% in 6 months. I have organized another meeting in MMESA meeting in Italy, Catania in the 18 November 2011 where many experts will deal with the plication. We had a hot meeting in IFSO in last sept in Hamburg as well. I am happy with this procedure because my patients are happy and I have better results than the sleeve comparing 127 cases ( 70 plications and 50 sleeves) since last february 2011 . My e mail is tyre_ lap@hotmail.com for more information . Thanks