Role of CT Volumetry In Evaluation of Gastric Plication

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Kernel for Word to PDF DemoRole of CT Volumetry In Evaluation of Gastric Plication

M. Hassan*MD and A.Bravo**MD

*General Surgery Department, Kasr El Aini, Cairo University.

** General Surgery Department, Badr Hospital, Helwan University.

ABSTRACT

Laparoscopic greater curve plication (LGCP) is a relatively new bariatric

restrictive procedure. To our knowledge this is the first study which used Computed

tomography (CT) volumetry, for quantitative as well as qualitative assessment of

LGCP. CT volumetry, was used to assess the gastric pouch volume 1, 6, and 12

months following LGCP, We compared the gastric pouch volume for 30 cases

performed at Cairo University, Egypt and observed the relation of the volume

changes to the patients' weight loss.

Keywords Gastric plication, pleat, imbrication, Laparoscopic greater curve plication, GCP,

LGCP, Computed tomography (CT) volumetry, pouch volume, virtual Gastroscopy,

anatomical abnormalities, quantitative and qualitative assessment of LGCP

INTRODUCTION

LGP is an emerging procedure that requires additional studies to

assess long-term efficacy. Initial studies suggest that LGP may provide

effective surgical weight loss with a potentially lower risk profile than

other bariatric procedures (1).

CT volumetry has proven its efficacy in evaluation of the volume

of other organs, such as the liver, but has not been widely used in

assessing the stomach. More research is needed in order to prove its

accuracy with this particular organ, which, if done, should provide a true

evolution in the prediction of the outcome of the restrictive bariatric

procedures (2)

PATIENTS AND METHODS

The present study included 30 randomly selected morbidly obese

patients who underwent LGCP in kasr el Aini hospital, Cairo University

after the approval of the ethical committee between May 2010 & October

2012.

The patients' ages ranged from 18 to 48 years old with a mean of

32.7 years. Out of 30 patients 21 were females and 9 were males.

Preoperative BMI ranged from 40 to 62 kg/m2 with a mean BMI of 50.6

kg/m2. Patients were informed about the nature of the research, and each

patient understood and agreed to the procedure. Kernel for Word to PDF Demo









All patients underwent a standard evaluation preoperatively as

required.

Surgical Procedures

All surgical procedures took place under general anesthesia with

the patient in supine position with 30 degrees reverse trendlenberg and

legs open. Closed pneumoperitoneum was achieved then a five-trocar

port technique similar to that used in laparoscopic sleeve gastrectomy was

used. Trocar placement was as follows: one 10-mm trocar above and

slightly to the right of the umbilicus for the 45° laparoscope; one 10-mm

trocar in the upper right quadrant (URQ) for passing the needle, for

suturing, and for the surgeon’s right hand; one 5-mm trocar also in the

URQ below the 10-mm trocar at the axillary line for the surgeon’s

assistant; one 10-mm trocar below the xiphoid process for liver retraction;

and one 5-mm trocar in the upper left quadrant (ULQ) for the surgeon’s

left hand (Fig. 1). The procedure began with dissection of the Greater

curvature from attached omentum using Ligasure (Covedien) or

Harmonic scalpel (Ethicon Endo-Surgery) and 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 proximally up to the Angle of His and distally

until 4cm from the pylorus. Posterior gastric adhesions were also

dissected to allow optimal freedom for creating and sizing the

invagination properly.

Fig. (1): Trocar position: A) 10mm above the umbilicus slightly to the right; B) 10mm in

URQ; C) 10mm below xiphoid process; D) 5mm in the ULQ; E) 5mm on the URQ at the

axilary line










After release of the greater curvature Plication was started at the

angle of Hiss and continued to 4cm from the pylorus over a 36 Fr. Bougie

using an extra-mucosal running suture line of 0-0 Prolene™ (Ethicon,

Inc., Somerville, NJ, USA). The suture material was then knotted and a

second running suture line applied ending at the angle of Hiss. The

distance between each stitch and lesser curvature was 2cm anteriorly as

well as posteriorly. The distance between each stitch and the following

stitch was 2cm as well. Care was taken to keep the stitches extramucosal.

The reduction resulted in a stomach shaped like a large sleeve

gastrectomy. Leak tests were performed with methylene blue and then

repeated with air in all cases. One drain was left in place and ports closed.

All intra-operative videos were digitally recorded.

In the postoperative period, patients were discharged as soon as

they accepted a liquid diet without vomiting. The postoperative diet was

prescribed with a progressive return to solid foods in a stepwise fashion.

The primary study objective was to assess relation between CT

volumetric results and the weight loss after gastric plication. The weight

loss assessments included the absolute change in weight, the change in

BMI, and the percentage of excess Body weight loss (%EBWL). The

weight was measured at the initial screening visit, 1 month, 6 months, and

12 months after surgery. CT volumetric and Virtual gastroscopic

evaluations were scheduled for 1, 6, and 12 months.

All available data was placed in Excel spreadsheet software and the

data analyzed.

RESULTS

The absolute weight decreased at 1 month postoperative by a mean

of 16.1 kg with a range of 3.6 kilograms (kg) to 27.5 kg. The absolute

weight decreased at 6 months postoperative by a mean of 29.3 kg with a

total weight loss range of 12 kg to 51 kg. The absolute weight decreased

at 12 months postoperative by a mean of 36 kg with a total weight loss

range of 4 kg to 71 kg as shown in figure (2).










Fig. (2): The mean absolute weight preoperative, 1 month, 6 months, and 12 months

postoperative.

The mean BMI decreased at 1 month to 44.7 kg/m2 (34.7 – 56.1

kg/m2). At 6 months the mean BMI was 39.9 kg/m2 (28.5 – 52.8 kg/m2),

and after 1 year the mean BMI was 37.5 kg/m2 (25.1 – 51.9 kg/m2). The

BMI of all patients over a 12 months period is shown in figure (3). While

the mean BMI over 12 months is shown in figure (4).

The BMI decreased at 1 month postoperative by a mean of 5.9

kg/m2 with a range of 1.4 kg/m2 to 10.8 kg/m2. The BMI decreased at 6

months postoperative by a mean of 10.7 kg/m2 with a range of 4.6 kg/m2

to 17.4 kg/m2. The BMI decreased at 12 months postoperative by a mean

of 13.2 kg/m2 with a range of 1.5 kg/m2 to 26 kg/m2.

0

20

40

60

80

100

120

140

160

Preoperative 1 month 6 months 12 months

Mean weight










Fig. (3): The BMI of all patients preoperative, 1 month, 6 months, and 12 months

postoperative.

Fig. (4): The mean BMI preoperative, 1 month, 6 months, and 12 months postoperative.

The % excess body weight loss ranged from 9.1 % to 47.7 %

with a mean of 23.5 % after 1 month. After 6 months, the % excess body

weight loss ranged from 21.1 % to 80.9 % with a mean of 43.5 %. While

After 12 months, the excess body weight loss ranged from 10.2 % to 99.6

% with a mean of 52.4 %.

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29

12 months BMI

6 months BMI

1 month BMI

Preoperative BMI

0

10

20

30

40

50

60

Preoperative 1m. 6m. 12m.

Mean BMI










Fig. (5): The mean % EBWL at 1 month, 6 months, and 12 months postoperative.

The pouch volume ranged 1 month postoperative from 128 cm3 to

446 cm3 with a mean of 248 cm3. This volume ranged 6 months

postoperative from 168 cm3 to 573 cm3 with a mean of 356.5 cm3. The

volume at 12 months postoperative ranged from 277 cm3 to 822.2 cm3

with a mean of 458.1 cm3.

The pouch volume increased at 6 months postoperative by a mean

of 108.6 cm3 with a range of 28 cm3 to 307 cm3. The volume increased

at 12 months postoperative by a mean of 210.2 cm3 with a range of -35.1

cm3 to 499.2 cm3 from the pouch volume at 1 month postoperative as

shown in figure (6)

0

10

20

30

40

50

60

1m. 6m. 12m.

% EBWL










Fig. (6): The mean pouch volume at 1 month, 6 months, and 12 months postoperative.

Qualitatively CT volumetry suggested that the initial greater

curvature fold was smaller at 6 months when compared with the initial

fold size at 1 month but appears unchanged at 12 months.

The mean operative time was 154 min (100 to 210 min). Operative

time was shown to decrease by time. The mean operative time was 163.6

min. (120 – 210 min.) in the first 22 cases who underwent surgery in

2010, while it decreased to 130 min. (100 – 150 min.) in the last 8 cases

who underwent surgery in 2011.

The Patients’ data is shown below in table (1):

No Age (y) Sex Date of Operation Operative time (min)

1 27 F 12/05/10 120

2 44 F 15/06/10 180

3 23 F 31/6/10 200

4 28 F 04/07/10 180

5 29 F 06/07/10 210

6 28 F 10/07/10 160

7 35 M 20/07/10 160

8 25 M 05/08/10 130

9 19 M 07/08/10 180

10 47 F 09/08/10 160

11 30 F 23/08/10 180

0

50

100

150

200

250

300

350

400

450

500

1 month 6 months 12 months

Mean pouch volume

Mean pouch volume










12 31 M 29/08/10 180

13 30 F 03/09/10 140

14 27 F 06/09/10 200

15 30 M 07/09/10 180

16 46 F 13/09/10 140

17 38 F 14/09/10 135

18 26 F 20/09/10 120

19 48 F 07/10/10 130

20 42 M 08/10/10 120

21 27 F 18/10/10 195

22 38 M 20/12/10 180

23 35 F 23/01/11 130

24 30 M 05/03/11 140

25 32 F 13/4/11 130

26 18 F 04/05/11 130

27 31 F 17/05/11 150

28 38 F 30/5/11 100

29 48 M 03/06/11 140

30 33 F 30/10/11 120

*The following abbreviations were used in the table to easily display the data: number (No.),

Female (F), Male (M)

The Preoperative Biometric measurements are shown below in

table (2):

No.

Preoperative measurements

Weight Height BMI Ideal Weight Excess body weight

1 140 1.67 50.2 69.7 70.3

2 139 1.64 51.7 67.2 71.8

3 115 1.67 41.2 69.7 45.3

4 141.5 1.6 55.3 64.0 77.5

5 113 1.61 43.6 64.8 48.2

6 105 1.62 40.0 65.6 39.4

7 148 1.62 56.4 65.6 82.4

8 195 1.8 60.2 81.0 114.0

9 180 1.79 56.2 80.1 99.9

10 147 1.59 58.1 63.2 83.8

11 138 1.64 51.3 67.2 70.8

12 122 1.71 41.7 73.1 48.9

13 140 1.68 49.6 70.6 69.4

14 110 1.47 50.9 54.0 56.0

15 150 1.64 55.8 67.2 82.8

16 101 1.55 42.0 60.1 40.9

17 144 1.59 57.0 63.2 80.8

18 158 1.7 54.7 72.3 85.8

19 105.4 1.59 41.7 63.2 42.2

20 152 1.84 44.9 84.6 67.4 Kernel for Word to PDF Demo









21 150 1.64 55.8 67.2 82.8

22 157 1.87 44.9 87.4 69.6

23 125 1.58 50.1 62.4 62.6

24 157 1.72 53.1 74.0 83.0

25 157.5 1.63 59.3 66.4 91.1

26 117 1.68 41.5 70.6 46.4

27 120 1.68 42.5 70.6 49.4

28 147 1.54 62.0 59.3 87.7

29 136 1.64 50.6 67.2 68.8

30 147 1.62 56.0 65.6 81.4

The results after 1 month are shown below in table (3):

No. 1 Month Postoperative

BMI Weight Weight Loss % Excess Weight Loss CT volumetry (Pouch volume)

1 45.5 127.0 13.0 18.5 231

2 41.6 112.0 27.0 37.6 176

3 39.0 108.9 6.1 13.5 246

4 50.4 129.0 12.5 16.1 229

5 34.7 90.0 23.0 47.7 139

6 38.6 101.4 3.6 9.1 395

7 49.5 130.0 18.0 21.8 323

8 54.0 175.0 20.0 17.5 340

9 51.4 164.7 15.3 15.3 224

10 51.8 131.0 16.0 19.1 225

11 42.0 113.0 25.0 35.3 303

12 37.9 110.9 11.1 22.7 208

13 46.1 130.0 10.0 14.4 140

14 47.2 102.0 8.0 14.3 280

15 50.6 136.0 14.0 16.9 280

16 38.3 92.0 9.0 22.0 333

17 46.1 116.6 27.4 33.9 194

18 48.4 140.0 18.0 21.0 290

19 36.8 93.0 12.4 29.4 205

20 39.9 135.0 17.0 25.2 250

21 48.3 130.0 20.0 24.2 169

22 42.4 148.3 8.7 12.5 214

23 46.7 116.6 8.4 13.4 197

24 46.3 137.0 20.0 24.1 213

25 48.9 130.0 27.5 30.2 227

26 35.4 100.0 17.0 36.6 199

27 35.4 100.0 20.0 40.5 340

28 56.1 133.0 14.0 16.0 295

29 42.0 113 23.0 33.4 446

30 48.8 128 19.0 23.3 128










The results after 6 months are shown below in table (4):

No. BMI Weight Weight Loss % Excess

Weight Loss

CT volumetry

Pouch

volume cc

Volume

increase cc

% volume

increase 1 41.2 115 25 35.6 359.0 128.0 55.4

2 36.1 97 42 58.5 284.0 108.0 61.4

3 34.0 94.8 20.2 44.6 317.0 71.0 28.9

4 45.7 117 24.5 31.6 307.0 78.0 34.1

5 28.5 74 39 80.9 233.0 94.0 67.6

6 35.4 93 12 30.5 573.0 178.0 45.1

7 46.5 122 26 31.6 462.0 139.0 43.0

8 52.8 171 24 21.1 450.0 110.0 32.4

9 40.3 129 51 51.1 347.0 123.5 55.3

10 46.7 118 29 34.6 532.0 307.0 136.4

11 39.0 105 33 46.6 384.0 81.0 26.7

12 29.1 85 37 75.7 321.0 113.0 54.3

13 42.2 119 21 30.2 168.0 28.0 20.0

14 42.6 92 18 32.2 363.0 83.0 29.6

15 47.2 127 23 27.8 375.0 95.0 33.9

16 33.3 80 21 51.3 450.0 117.0 35.1

17 39.6 100 44 54.5 302.0 108.0 55.7

18 44.3 128 30 35.0 362.5 72.5 25.0

19 34.0 86 19.4 46.0 314.0 109.0 53.2

20 37.2 126 26 38.6 331.0 81.0 32.4

21 39.0 105 45 54.4 262.0 93.0 55.0

22 36.6 128 29 41.7 331.0 117.0 54.7

23 38.9 97 28 44.7 289.0 92.0 46.7

24 41.9 124 33 39.7 339.0 126.0 59.2

25 42.5 113 44.5 48.9 270.0 43.0 18.9

26 31.5 89 28 60.3 312.0 113.0 56.8

27 32.2 91 29 58.7 407.8 67.8 19.9

28 52.7 125 22 25.1 368.0 73.0 24.7

29 40.2 108 28 40.7 568 122.0 27.4

30 45.3 119 28 34.4 314 186.0 145.3

The results after 12 months are shown below in table (5):

No. BMI Weight Weight Loss % Excess

Weight Loss

CT volumetry

Pouch

volume cc

Volume

increase cc

% pouch

volume 1 36.2 101 39.0 55.5 401.9 170.9 74.0

2 32.7 88 51.0 71.1 388 212 120.5

3 34.1 95 20.0 44.2 460 214 87.0

4 41.0 105 36.5 47.1 483 254 110.9

5 25.1 65 48.0 99.6 377 238 171.2

6 38.5 101 4.0 10.2 813 418 105.8

7 41.9 110 38.0 46.1 822.24 499.24 154.6

8 51.9 168 27.0 23.7 577.6 237.6 69.9 Kernel for Word to PDF Demo









9 37.1 119 61.0 61.1 412 188.5 84.3

10 43.1 109 38.0 45.3 470 245 108.9

11 39.0 105 33.0 46.6 327.4 24.4 8.1

12 32.1 94 28.0 57.3 542 334 160.6

13 40.7 115 25.0 36.0 323 183 130.7

14 44.0 95 15.0 26.8 512 232 82.9

15 42.4 114 36.0 43.5 476 196 70.0

16 31.2 75 26.0 63.5 604 271 81.4

17 36.4 92 52.0 64.4 436 242 124.7

18 42.2 122 36.0 42.0 586 296 102.1

19 32.4 82 23.4 55.5 467 262 127.8

20 33.1 112 40.0 59.4 364 114 45.6

21 29.7 80 70.0 84.6 284 115 68.0

22 34.3 120 37.0 53.2 307 93 43.5

23 37.3 93 32.0 51.1 277 80 40.6

24 39.5 117 40.0 48.2 299.9 86.9 40.8

25 41.4 110 47.5 52.2 493 266 117.2

26 30.1 85 32.0 68.9 543.5 344.5 173.1

27 28.3 80 40.0 80.9 483.2 143.2 42.1

28 48.5 115 32.0 36.5 502.6 207.6 70.4

29 37.9 102 34.0 49.4 410.9 -35.1 -7.9

30 41.2 108 39.0 47.9 299.9 171.9 134.3

DISCUSSION

The mean BMI decreased at 1 month to 44.7 kg/m2 (34.7 – 56.1

kg/m2). At 6 months the mean BMI was 39.9 kg/m2 (28.5 – 52.8 kg/m2),

and after 1 year the mean BMI was 37.5 kg/m2 (25.1 – 51.9 kg/m2).

The BMI decreased after 12 months postoperative by a mean of

13.2 kg/m2 with a range of 1.5 kg/m2 to 26 kg/m2. In the study by

Brethauer S. et. al. The mean BMI decreased by 24.4 Kg/m2 (3). The

difference could possibly be due the smaller preoperative BMI in the

study by Brethauer S. et. al. 43.3 Kg/m2 (range 36.9 – 49 Kg/m2)

compared to our study with a mean BMI of 50.6 kg/m2 (range 40 - 62

kg/m2 ). The results are shown in figure (7)










Fig. (7): The mean decrease in BMI after 12 months postoperative.

All the patients have lost weight significantly after 1 month, 6

months and 12 months with a mean % Excess Body Weight Loss of 23.5,

43.5% and 52.4% respectively. This was compared to other studies as

follows:

0

5

10

15

20

25

30

Our study Brethauer S. et. al., 2010

Mean decrease in BMI after 12 months










Fig. (8): The mean % EBWL at 1 month, 6 months, and 12 months postoperative (3)(4)(5).

In our study, we measured the pouch volume after 1 month which

showed a mean volume of 248 cm3 which increased after 6 months to

356.5 cm3 and after 12 months to 458.1 cm3. The pouch volume in all

patients at 1 month, 6 months, and 12 months is shown in figure (9). The

pouch volume increased in most but not all patients which suggests that

patient factors of gradual overstretching of the pouch may play a role.

Therefore gradual eating beyond satiety and thus gradual stretching of the

pouch should be avoided. The mean pouch volume at 1 month, 6 months,

and 12 months postoperative is shown in figure (10).

0

10

20

30

40

50

60

70

1m. 6m. 12m.

Our study Ramos et. al., 2010

Brethauer S. et. al., 2010 Talebpour 2007

Talebpour 2010










Fig. (10): The mean pouch volume at 1 month, 6 months, and 12 months postoperative.

The percentage pouch volume increase was compared at 6 months

and 12 months postoperative. The mean gastric pouch increased in

patients after 6 months by 47.8% (108.6 cm3) and after 12 months the

pouch further increased by a mean of 43.6 % (101.6 cm3) of the mean

volume at 1 month. The % pouch volume increase in all patients at 6

months and 12 months is shown in figure (11)

0

100

200

300

400

500

1 month 6 months 12 months

Mean pouch volume

Mean pouch volume

Fig. (9): The pouch volume at 1 month, 6 months, and 12 months postoperative.

0

200

400

600

800

1000

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Pouch volume 1 month Pouch volume 6 months Pouch volume 12 months










Fig. (11): The % pouch volume increase at 6 months, and 12 months postoperative.

The mean % pouch volume increase in patients was compared to %

EBWL at 6 months and 12 months and it was found that a mean % pouch

volume increase of 47.8% was associated with a mean %EBWL of

43.5%. Over the next 6 months. The mean % pouch volume increased by

a further 43.6%. This was associated with a mean % EBWL of 52.4

(8.9% more than the mean %EBWL at 6 months). Therefore if the mean

% EBWL at 6 months is considered theoretically constant in the next 6

months, an increase of mean % pouch volume by 43.6 decreased the

potential weight loss by 34.7%. Therefore it can be deduced that an

increase in pouch volume strongly correlates with a decrease in %EBWL

This is shown in figure (12, 13)

-2.0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

% Pouch volume increase at 6 months % Pouch volume increase at 12 months










Fig. (12): The % pouch volume increase at 6 months, and 12 months postoperative compared to

mean % EBWL.

Fig. (13): (a) The % pouch volume increase at 1, 6, 12 months (b) The mean % EBWL a1, 6, and 12

months postoperative with linear projected % EBWL.

0

10

20

30

40

50

60

70

80

90

100

6 months 12 months

Mean % pouch volume

increase

Mean % EBWL

0

10

20

30

40

50

60

70

1 6 12

Mean % EBWL

Projected % EBWL

Linear (Projected % EBWL)










The % pouch volume increase at 6 months was compared and

found to strongly correlate with the % EBWL at 6 months as shown in

figure (14).The % pouch volume increase at 6 months was also found to

be a strong predictor of the % EBWL at 12 months as shown in figure

(15).

Fig. (14): The % pouch volume increase at 6 months compared to the % EBWL at 6 months.


0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

% Pouch volume increase at 6 months % EBWL at 6 months

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30











The % pouch volume increase at 12 months was also compared and

found to strongly correlate with the % EBWL at 12 months and will also

probably be a strong predictor of the % EBWL in the following period.


Analyzing this data, we observed that 13/15(86.6%) who had

significant weight loss (>50% of EBWL), had a smaller pouch volume

(<250cm3) following LGCP. Moreover, 9/15 (60%) of the patients who

had significant weight loss (>50% of EBWL) had a lower percentage of

increased gastric pouch volume in the first 6 months (≤ 55% increase in

the pouch volume) i.e. the lesser the increase of the pouch volume, the

more the weight loss of the patients. This is shown in figure (17)

-2.0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30











Fig. (17): Relation between %EBWL and % increased Pouch Volume.

CONCLUSIONS

Therefore it can be concluded that the pouch volume following

LGCP and the percentage of volume increase of this pouch are two

important factors in determining the weight loss of the patients. However

this relation was not proven in 100% of the patients which highlights the

possible effect of other factors such as hormonal factor or the increased

rate of pouch evacuation.

These results emphasize the fact that CT volumetry is mandatory in

evaluation of EBWL in relation to the dilated gastric pouch and further

study to determine the exact end point for predictability of outcome in

relation to pouch volume must be studied.

Patients with > 50% EBWL

Increased pouch volume ≤ 55% Increased pouch volume > 55%










REFERENCES

1 ASMBS guideline on the prevention and detection of

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imaging and surgical exploration. Surg Obes Relat Dis 2009;

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2 Kim WW, Gagner M, Kini S, Inabnet WB, Quinn T, Herron D,

Laparoscopic vs. open biliopancreatic diversion with duodenal

switch: a comparative study. J Gastrointest Surg ;2003 7:552-7

3 Brethauer SA, Harris JL, Kroh M Laparoscopic gastric plication

for the treatment of severe obesity. Surgery for Obesity and

Related Diseases May 2010; 6(3):S16.

4 Ramos A.C., Manoel Galvão Neto, Josemberg Marins Campos,

and Claudio Cora Mottin, Laparoscopic Greater Curvature

Plication: An alternative restrictive bariatric procedure Bariatric

Times. 2010; 7(5):8–10

5 Talebpour M, Amoli BS. Laparoscopic total gastric vertical

plication in morbid obesity. J Laparoendosc Adv Surg Tech A.

2007; 17(6):793–8.

6 Talebpour M., Hamed Vahidi, Ten Years’ Experience about the

New Technique “laparoscopic vertical gastric plication” in morbid

obesity introduced the first time in the world http://www.

Laparoscopic

gastricplication.com/en/PUBLICATIONS_ABOUT_TVGP/ last

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Role of CT Volumetry In Evaluation of Gastric Plication

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