What happens in Gastric Imbrication
Dr. Sunil K. Sharma from the University of Florida, talks about a new experimental procedure that is helping patients shrink their stomach in a new and innovative way.
Dr. Sunil K Sharma: This is one of the latest weight loss surgeries and essentially, in any form weight loss surgery, there are two basic concepts, one is to shrink the stomach, or reduce the capacity of the stomach, and there are other operations like gastric by-pass which, besides shrinking the stomach, also by-passes a certain portion of the intestine so there is less absorption of calories. So, in shrinking the stomach there are two main operations. One we call Sleeve Gastrectomy in which we remove 90% of the stomach. It involves stapling of the stomach and excising it. The other one is Lab Band, in which a silicon band is placed at the top portion of the stomach, which is a foreign body, and you adjust it so you get a smaller portion. In this imbrication study, what we try to do is, using the same principle of reducing the volume of the stomach, not by stapling or using any foreign body, but trying to invoke the stomach on its own. We call imbrication and we use non-absorbent sutures to do this operation. Basically, you mobilize the portion of the stomach and start butting stomach on its own so that without cutting or stapling, or using a foreign body, you can shrink the lumen of the stomach almost by 90%.
So are you rolling it?
Dr. Sunil K Sharma: Not rolling it but pushing it in and putting in sutures. So a portion of the stomach goes inside the lumen. Basically, the lumen available for the food is much smaller and that translates to easy filling of the stomach but eating less quantity of food, controlling the appetite of the patients and thereby translating to all the beneficial affects like weight loss and the correction of all the medical problems.
Is there also an advantage here because it is not as invasive, and there are not many foreign things introduced? And what are the advantages in terms of the extent of the complexity of the surgery?
Dr. Sunil K Sharma: The concept is very good. The beauty of this operation is that we are not using any foreign body or stapling and shrinking the stomach. We are not removing any part of your stomach so the stomach is essentially the same, but the capacity of the lumen is much more reduced. Since we are not using any stapling to a degree there is less chance of leakage. There is another theoretical advantage; let’s say if someone doesn’t tolerate or we have to reverse it, all we have to do is cut the sutures. It may get back to normal size.
Conversely, if the stomach starts to stretch?
Dr. Sunil K Sharma: Then you can put additional sutures. If the patient doesn’t follow the proper lifestyle adjustment that is needed then doing a divisional surgery and gastric by-pass is 5 – 10 times more complex and has much more complication. Theoretically, we can shrink it again by putting some extra sutures. We have not reached that point since this is a very new operation, but we think that should be a very easy option.
How many of these surgeries have you done and what kind of success stories have you seen over the longer term?
Dr. Sunil K Sharma: Well, this concept was originated about three years back from a Greek surgeon and we were really impressed by the concept. We then went and started the pilot study. We performed seven operations and we found technically it is very doable. It can be reproduced and we saw early quick results. Based on that, this operation is essentially, identical to Sleeve Gastrectomy without having the complications that Sleeve has. So what we did was a randomized trial comparing Sleeve Gastrectomy with imbrication. We performed 30 surgeries a year ago and in a very short follow up of about one year, we found that the weight loss is as good as Sleeve Gastrectomy and in the short duration at least we know it works well.
Do you know in the patients you have already done what is the average weight loss is a year out?
Dr. Sunil K Sharma: We measure weight loss in terms of excessive weight loss and in one year it was close to 40%. We are going to review all results in December and then I can give you the exact number but it closely matches the other restrictive operations.
Explain what you mean by 40%.
Dr. Sunil K Sharma: 40% excessive weight is, whatever the patient’s excess weight, they have lost 40% of it.
How many of these operations have you done?
Dr. Sunil K Sharma: We have performed the clinical trial, which includes 30 patients, people from last year and we just started a program at University of Florida, Jacksonville. We did the first surgery a week and a half ago and before this we did a pilot study for seven patients. There is very little experience around the globe. There are some surgeons in Brazil doing it. There was a clinical trial at the Cleveland Clinic that performed 15 surgeries and one of the surgeons, Dr. Dan Carter of Salt Lake City, he was involved with me in these trials and he has performed a bunch of these surgeries in Salt Lake City.
But the surgery alone is not enough, is it? The patients have to make a commitment too.
Dr. Sunil K Sharma: Yes. Surgery is a tool. A very powerful tool, which we put in the patient’s hand and they have to use it appropriately. If they don’t use it right, you can fail any surgery. So, patient education and understanding how this works is very important and this education has to be reinforced. We have support groups and other information sessions and this is an ongoing process.
What’s the patients part of the deal? What do they have to do? You do the surgery. What do they have to do?
Dr. Sunil K Sharma: Well, they have to leave certain habits. For example, if someone is smoking and not willing to give up smoking then we should not offer these surgeries because it puts the patient at extra risk of developing ulcers. More important, this tells me that the patient is not willing to change his lifestyle. Patients have to eat the right way. A good amount of proteins, a little bit of carbs, fat, anything in moderation is good. We have a diet plan taking three meals, and avoid snacking and take your time, chew it well, all the healthy things. It takes a certain time for the brain to adjust that they have this new stomach. And once they lose weight, they become lighter, they can walk around and enjoy exercise and other things. So, basically, eating right and exercising and not doing things that they are not supposed to do like smoking, that’s all we ask for and lifelong follow up with the surgical team so if they develop any deficiency or anything we can correct it.
Is there anything else you want to say about this that you have not said?
Dr. Sunil K Sharma: The other good thing about this operation is that it is essentially a physiologic; we do not change the anatomy much. It doesn’t cause mal absorption like one of the things you worry about in Gastric By-pass is vitamins and minerals deficiency. You will lose too much weight and you have to take vitamins for the rest of your life. This is essentially a physiologic that is the same stomach continuity, except you are satisfied eating a small amount of food and it should not cause much mal absorption. I’m hoping it is relatively safer, technically easier, and can be reproduced by many other surgeons. This procedure is still investigational and the early results are very encouraging. Up to now all the procedures in bariatric surgery, namely gastric bypass that is a gold standard, sleeve, band and there have been others done in the past. None of these operations is perfect. If there is anything close to perfect, I believe this may be the future operation. But, it’s too early to say at this point having very little follow up over the long term. But, we are very excited and hopefully this surgery should help a lot of patients who are looking to lose weight and curing their medical problems.
END OF INTERVIEW
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