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Revisional sleeve gastrectomy after failed gastric clipping for obesity: Report of two cases and review of literature


1 Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei; Division of General Surgery, Department of Surgery, Hualien Armed Forces General Hospital, Hualien, Taiwan
2 Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei; Division of General Surgery, Department of Surgery, Taichung Armed Forces General Hospital, Taichung, Taiwan
3 Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

Date of Submission07-Jul-2021
Date of Acceptance13-Sep-2021
Date of Web Publication08-Nov-2021

Correspondence Address:
Kuo-Feng Hsu,
Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu 114, Taipei
Taiwan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_229_21

  Abstract 


Laparoscopic gastric clipping (LGC) is one of the bariatric surgeries that are minimally invasive and demonstrates effectiveness in reducing body weight for obese patients. However, the patients may later regain body weight and other treatments may be needed. In this case report, two cases with obesity received LGC, which initially reduced their weight. However, they presented with a progressive regaining of body weight a few years after the surgery. Thus, revisional sleeve gastrectomy was conducted in an institute to control their weight regain. Postoperative courses were smooth, and there was no complication. Thus, laparoscopic removal of gastric clipping accompanied with revisional sleeve gastrectomy is technically feasible for the patients.


Keywords: Body weight regain, gastric clipping, laparoscopic sleeve gastrectomy, obesity, revision



How to cite this URL:
Yen C, Tsai WT, Pan HM, Hsu KF. Revisional sleeve gastrectomy after failed gastric clipping for obesity: Report of two cases and review of literature. J Min Access Surg [Epub ahead of print] [cited 2021 Dec 9]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=330043





  Introduction Top


Morbid obesity is refractory to conservative treatment and brings comorbidities (e.g., hyperlipidemia, hypertension, hyperuricemia, and diabetic mellitus).[1] Thus, laparoscopic gastric clipping (LGC) was developed in 2004 to modify the anatomy of the gastrointestinal (GI) tract by creating a restrictive mucosa tunnel only approximately 0.6 cm in diameter between the clipped gastric walls, causing reduced caloric intake and sustained weight loss. Since the procedure of gastric clipping is simple and no resection of stomach, it has become popular in Taiwan in recent years.[1] However, patients who received bariatric surgery may later regain body weight. Herein, two cases that suffered from weight increase and received revisional sleeve gastrectomy were collected, which was probably the second case report. The relevant published literature was reviewed.


  Case Presentation Top


Patient 1

A 29-year-old Taiwanese female patient was diagnosed with Grade I obesity (163 cm; 85.6 kg; body mass index [BMI] = 32.2 kg/m2) and impaired fasting glucose. No hiatus hernia or gastroesophageal reflux disease (GERD) was noted by panendoscopy (PES) preoperatively. The patient received LGC in May 2016 at another institute [Figure 1]a. The metallic clip is a rod of 0.3 cm in diameter and it is in the shape of hair clip with 10 cm in length, 1.5 cm in height, and 0.9 cm in width. The gastric clip is placed between the lesser curvature and the angle of His.[1] However, the patient's body weight did not effectively decrease after the operation. Consequently, the patient visited our hospital and sought a second opinion in 2019. The patient's dyslipidemia (high-density lipoprotein [HDL] = 46 mg/dL, low-density lipoprotein [LDL] = 176 mg/dL, total cholesterol = 263 mg/dL, and triglyceride = 449 mg/dL) as well as serum fasting glucose (113 mg/dL) could be detected before preoperative evaluation. Previous gastric metallic clip retention was found in the patient's chest plain film. Moreover, PES revealed a hiatal hernia with Grade B GERD. Thus, the current study conducted gastric metallic clip laparoscopic removal, hiatal hernia repair, and sleeve gastrectomy in May 2019 [Figure 1]b and [Figure 1]c. The patient's latest body weight 2 years after the operation during follow-up was 62 kg (BMI = 23.3 kg/m2).
Figure 1: Images of patient 1. (a) Chest plain film showing a metallic gastric clip over the gastroesophageal junction. (b) Severe adhesion between the lesser curvature and the left lobe of the liver. (c) Specimen and the retrieved gastric metallic clip

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Patient 2

A 22-year-old Taiwanese female patient suffered from morbid obesity for years. The patient's initial body height, body weight, and BMI were 161 cm, 120 kg, and 46.3 kg/m2, respectively. Preoperative PES showed no hiatus hernia or GERD. She underwent LGC in June 2016 at another institute [Figure 2]a. Consequently, the patient's body weight decreased to 96 kg at most after the surgery. However, the patient gradually regained weight and body weight started to increase to 110 kg in 2018. The patient then visited our outpatient department (OPD) for help in 2020. Serologic examination disclosed low HDL (46 mg/dL), elevated LDL (113 mg/dL), and elevated alanine aminotransferase (65 U/L). No other abnormal data were noted. The patient's chest plain film found previous gastric metallic clip retention, and upper GI PES disclosed hiatal hernia with GERD (Grade A). Surgical treatment with gastric metallic clip laparoscopic removal, hiatal hernia repair, and sleeve gastrectomy was performed in August 2020 [Figure 2]b and [Figure 2]c. The postoperative recovery was uneventful, and the patient visited OPD for regular follow-up. The patient received body weight measurement 10 months after the surgery at 79 kg (BMI = 30.5 kg/m2). The characteristics of the two patients are summarized in [Table 1].
Figure 2: Images of patient 2. (a) Chest plain film showing a metallic gastric clip over the gastroesophageal junction. (b) Hiatal hernia repair with absorbable mesh after adhesiolysis and removal of gastric clip. (c) Specimen and retrieved gastric metallic clip

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Table 1: The characteristics of the two patients in this study

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  Discussion Top


LGC can bring body weight loss in the following 2 years after the operation.[1] However, a chance for the patient to regain weight still exists, and other treatments may be needed.[2] Two cases that received revisional surgery after LGC were collected due to body weight regain. The postoperative recovery was uneventful during subsequent follow-up and the goal of body weight reduction could be achieved.

The metallic gastric clip should be carefully removed first by performing revisional surgery. The gastric metallic clip was a rod of 0.3 cm in diameter and it was designed similar to a hair clip with an opening at one end (specification: 10 cm in length, 1.5 cm in height, and 0.9 cm in width). The gastric clip was placed between the lesser curvature and the angle of His.[1] Proper suturing over the clip had been done for fixation and prevention of migration. Severe adhesion between the gastric serosal layer, gastric metallic clip, esophagogastric junction, and left lobe of the liver could be identified after entering the peritoneal cavity. Moreover, adhesion lysis should be carefully performed in case of perforation.[3] Consequently, sleeve gastrectomy could be performed as usual after the metallic gastric clip was freed and removed.

The current two cases were also found to have GERD and hiatal hernia during preoperative evaluations. The causes of de novo GERD and hiatus hernia following LGC may be due to the increased gastric pressure. Hiatal hernia repair was conducted during revisional sleeve gastrectomy. Moreover, the current study herein reports the experience of post-LGC patients receiving revisional surgery in the institute of this study. No mortality or immediate complications were noted in the patients, showing that concomitant hiatal hernia repair can be safe. However, a longer observation period is required to ensure its safety and efficacy. Laparoscopic removal of gastric metallic clip, hiatal hernia repair, and sleeve gastrectomy are technically feasible for the patients. Meticulous adhesiolysis between left lobe of the liver and stomach is a critical step due to the severe adhesion caused by gastric clip.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chao SH. Gastric clipping for morbid obesity: The initial results of a clinical trial. World J Surg 2010;34:303-8.  Back to cited text no. 1
    
2.
Chuang HY, Huang CK, Chang PC. Laparoscopic conversion to sleeve gastrectomy after gastric clipping for morbid obesity-video presentation. Obes Surg 2019;29:1433.  Back to cited text no. 2
    
3.
Chao SH, Lin CL, Lee WJ, Chen JC, Chou JJ. Proximal Jejunal bypass improves the outcome of gastric clip in patients with obesity and type 2 diabetes mellitus. Obes Surg 2019;29:1148-53.  Back to cited text no. 3
    


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2004 Journal of Minimal Access Surgery
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Online since 15th August '04