Gastric Plication Offers Some Benefits for Obese Patients

Bariatric surgeons owe it to their patients to offer operations that are most likely to be therapeutic, that have an excellent risk-benefit ratio, and that are durable, with long-term efficacy. Unfortunately, few bariatric operations have met those criteria. A new procedure should be done in limited numbers as an investigational procedure at an academic center or institution that will provide follow-up and will document the results. Dr. Brethauer and his colleagues at the Cleveland Clinic have an outstanding record for offering the complete range of bariatric surgery options at an institution that is a high-volume center with excellent outcomes.

Although initial results and safety of the GCP procedure are excellent, I am greatly concerned about the likely durability of this operation and its cost.

In the past, the proximal gastric pouch of a gastric bypass was performed by simply stapling across the stomach (without dividing it). Advocates of this approach cited its increased safety over dividing the stomach to create the pouch. Reports on the long-term outcomes of stapled and divided vs. just stapled stomachs for gastric bypass have clearly shown that just stapling results in a considerable incidence of long-term staple-line disruption, loss of the integrity of the restrictive component of the operation, subsequent weight regain, and development of marginal ulcers. So a "lesser" procedure turned out not to be as durable in the long term.

If the staple line of a stapled stomach can break down and allow restoration of continuity of the stomach, I think it’s highly likely that the plication sutures of the GCP will disrupt (from the stresses of eating, vomiting, and so on), and the patient will need revisional surgery. Furthermore, foreign bariatric surgeons who wish to attract American medical tourists are offering gastric plication. Some non-U.S. bariatric surgeons are performing large numbers of these procedures, not as Institutional Review Board procedures but as cash-pay procedures.

In the current climate of cost containment of health care, how much luxury will we have to provide an operation with a high incidence of failure that requires some form of reoperation? This could well be the case with the GCP.

It could be argued that the GCP is an excellent operation for individuals who are at higher risk for a more definitive but more involved operation, such as a gastric bypass. They would undergo a GCP, lose weight, then have a more definitive procedure once they were at a lower risk. That argument initiated performance of the sleeve gastrectomy, which now is rarely done for those circumstances relative to its frequency as a weight-loss operation for low-risk patients. If the GPC were offered only as a first-step procedure for high-risk patients, a second-step procedure would be needed, thereby increasing the overall cost of treatment. Although this added cost is likely justified on the basis of medical criteria, economic rather than medical criteria may be the determining factors in providing care in the future.

Bruce D. Schirmer, M.D., is an ACS Fellow and the Stephen H. Watts Professor of Surgery at the University of Virginia Health Sciences Center, Charlottesville. He had no disclosures to report.