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Classification of Slippage Following Laparoscopic BariClip Gastroplasty

Authors:
Patrick Noel at Phi Medcare
Patrick Noel
  • Phi Medcare
Stefano Olmi at Policlinico San Marco Zingonia (Bg)
Stefano Olmi
  • Policlinico San Marco Zingonia (Bg)
Paolo Gentileschi at University of Rome Tor Vergata
Paolo Gentileschi
Robert Caiazzo at Centre Hospitalier Régional Universitaire de Lille
Robert Caiazzo
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Abstract and Figures

Introduction Laparoscopic BariClip gastroplasty (LBCG) is a new reversible gastric sleeve-like procedure without gastrectomy proposed to minimize the risk of severe complications. Still one of the possible complications described with LBCG is slippage. The purpose of the current manuscript is to analyze different cases of slippage and propose a classification of this complication. Methods A number of 381 patients who underwent LBCG in 8 different centers were analyzed concerning the risk of slippage. All cases with documented slippage were carefully reviewed in terms of patients’ symptomatology (presence of satiety, vomiting), history of weight loss, radiological data, and management of their slippage. A new classification was proposed depending on the anatomy, the symptomatology, and the time of occurrence. Results We have identified a total of 17 cases (4.46%) of slippage following LBCG. In 11 patients, the slippage was symptomatic with repetitive vomiting and nausea, and in the remaining 6 patients, the slippage was identified by radiological studies for insufficient weight loss, weight regain, or routine radiological follow-up. Depending on the interval time, the slippage was classified as either immediate (in first 7 days) in 6 cases, early (in less than 90 days) in 4 cases, and late (after 3 months) in 7 cases. Evaluation of the radiological studies in these cases identified the following: anterosuperior displacement (type A) in 9 cases, posteroinferior displacement (type B) in 6 cases (one case after 3 months), and lateral displacement (type C) in the remaining 2 cases. The management of the slippage consisted of BariClip removal in 7 cases, repositioning in 5 cases, and conservative treatment in the remaining 5 cases. All patients with conservative treatment were recorded at the beginning of the experience. Conclusions Slippage is a possible complication after LBCG. This classification of the different types of slippage can benefit the surgeon in the management and treatment of this complication of LBCG. Graphical Abstract
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Obesity Surgery (2023) 33:3317–3322
https://doi.org/10.1007/s11695-023-06780-3
NEW CONCEPT
Classification ofSlippage Following Laparoscopic BariClip Gastroplasty
PatrickNoel1,2,3· StefanoOlmi4· PaoloGentileschi5· RobertCaiazzo6· CamilleMarciniak6·
DianaGabrielaMaldonadoPintado7· GilbertoUngson8· VicenteAlarcon9· SergioCarandina3· ThierryManos2·
JohnM.Shamoun10· NatanZundel11· RamiEdwardLut12· JaimePonce13· MariusNedelcu2,3
Received: 9 April 2023 / Revised: 1 August 2023 / Accepted: 10 August 2023 / Published online: 23 August 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023
Abstract
Introduction Laparoscopic BariClip gastroplasty (LBCG) is a new reversible gastric sleeve-like procedure without gastrec-
tomy proposed to minimize the risk of severe complications. Still one of the possible complications described with LBCG
is slippage. The purpose of the current manuscript is to analyze different cases of slippage and propose a classification of
this complication.
Methods A number of 381 patients who underwent LBCG in 8 different centers were analyzed concerning the risk of slip-
page. All cases with documented slippage were carefully reviewed in terms of patients’ symptomatology (presence of satiety,
vomiting), history of weight loss, radiological data, and management of their slippage. A new classification was proposed
depending on the anatomy, the symptomatology, and the time of occurrence.
Results We have identified a total of 17 cases (4.46%) of slippage following LBCG. In 11 patients, the slippage was symp-
tomatic with repetitive vomiting and nausea, and in the remaining 6 patients, the slippage was identified by radiological
studies for insufficient weight loss, weight regain, or routine radiological follow-up. Depending on the interval time, the
slippage was classified as either immediate (in first 7 days) in 6 cases, early (in less than 90 days) in 4 cases, and late (after
3 months) in 7 cases. Evaluation of the radiological studies in these cases identified the following: anterosuperior displace-
ment (type A) in 9 cases, posteroinferior displacement (type B) in 6 cases (one case after 3 months), and lateral displacement
(type C) in the remaining 2 cases. The management of the slippage consisted of BariClip removal in 7 cases, repositioning
in 5 cases, and conservative treatment in the remaining 5 cases. All patients with conservative treatment were recorded at
the beginning of the experience.
Conclusions Slippage is a possible complication after LBCG. This classification of the different types of slippage can benefit
the surgeon in the management and treatment of this complication of LBCG.
Keywords Obesity· Metabolic bariatric surgery· Adjustable gastric band· BariClip· Gastric sleeve· Vertical clip
gastroplasty· Slippage· Laparoscopic BariClip gastroplasty
Introduction
Bariatric and metabolic surgery today is considered the most
effective treatment for severe obesity for patients with BMI
over 35 kg/m2 or with metabolic disease and BMI 30–34.9
kg/m2. Laparoscopic sleeve gastrectomy (LSG) is the most
commonly performed bariatric procedure worldwide [1, 2].
New minimal endoscopic techniques and less aggressive
procedures are now proposed to minimize the risk of severe
complications recorded after traditional procedures and
allow reversibility of these treatments [3]. The laparoscopic
BariClip gastroplasty (LBCG) is a new reversible gastric
sleeve-like procedure without gastrectomy that involves a
Key points
➢ The anatomic preservation remains one of the major
advantages of LBCG with a similar restriction with the sleeve
described by the patient and illustrated by the postoperative
swallow studies.
➢ The current manuscript is improving the understanding of the
mechanism of action of different complications, especially the
slippage, essential for the purpose to prevent this complication.
➢ This classification of the different types of slippage can benefit
the surgeon in the treatment of this complication of LBCG.
Extended author information available on the last page of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... BariClip gastroplasty is indicated for patients seeking a restrictive and reversible bariatric procedure with reduced surgical trauma and potentially lower major complication rates compared to sleeve gastrectomy (SG). Initial short-term clinical results have shown comparable weight loss results to LSG with few complications and improved quality of life (QoL) [1,[3][4][5][6]. However, clip slippage can occur in 4 to 8% of cases with subsequent risk of occlusion and perforation [7]. ...
... The most reported complication related to LVCG is clip slippage that can occur in 4 to 7.7% of cases. Slippages can occur early, between 1 and 12 weeks post-surgery, or later [1,5,6]. Other reported complications include bleeding (1.3%) [7], erosion (1.4%-2.6%%), ...
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Laparoscopic Vertical Clip Gastroplasty with BariClip Experience, Complications, Literature Review, and Proposal of Modification of the Original Technique
Article
Full-text available
  • Dec 2024
  • OBES SURG
Laparoscopic vertical clip gastroplasty (LVCG) with BariClip is a recent procedure that appears to be safe Gentileschi et al. (Obes Surg 33(1):303-12, 2023). The initial complications reported include erosion, slippage, and gastroesophageal reflux. This study aimed to report on the experience of a single surgical group, analyzing three clinical cases, conducting a literature review, and proposing a standardization of the technique. A retrospective study was conducted with data from June 2021 to October 2024. We collected the data from the procedures related to the bariatric clip made by only one surgical group; we collected 69 cases with 1 complication of this surgical group. Additionally, we described 2 clinical cases of complications related to bariatric clips from other surgical institutions and reviewed the literature related to the BariClip experience. The results are related to the evaluation of the technique and compare the different modifications implemented over the last 3 years of follow-up. Furthermore, we aim to share our experience in attending to one of the most concerning complications associated with this procedure. The LVCG is a safe procedure with a low incidence of complications and positive results in %EWL. We propose several modifications to the original technique to further reduce complications, and we share the experience of both treating and resolving some of the complications we encountered.
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Evolving Technique of Laparoscopic Vertical Gastric Clip Placement
Article
Full-text available
  • Feb 2023
  • OBES SURG
Introduction: Laparoscopic BariClip gastroplasty (LBCG) will address a similar tubular restriction than the one achieved with the laparoscopic sleeve gastrectomy (LSG) at the level of the gastric fundus, while maintaining the advantage of simplicity and anatomic preservation. The purpose of the current study was to analyze the risk of slippage and to present the evolving technique by adding gastro-gastric plication of the gastric wall covering the BariClip at those areas where the gastric wall "slips" between the limbs of the clip. Methods: All patients undergoing LBCG with the evolving technique of gastric plication around the device associated with antral gastroplasty from January 2021 to May 2022 were included in the study group (group A). A control group (group B) was designed with patients who underwent previous LBCG technique between May 2017 and June 2019. This is a case-controlled group with patients matched by gender and BMI. We have analyzed the postoperative complications and more notably the slippage. Results: One hundred seventy-six patients (44 male and 132 female) with a mean age of 33 years (± 11) underwent evolving technique of LBCG. A control group of 67 patients who underwent previous technique of LBCG was included. All procedures were completed by laparoscopy with no intraoperative complication. For the study group, we have recorded a number of 5 slippages (2.8%). The diagnosis occurred during the first 6 months after the operation. The management consisted of repositioning-3 cases-and BariClip removal-2 cases. For the control group, we have recorded a number of 3 slippages (4.3%). All three patients underwent BariClip removal, with no repositioning. Conclusions: We reported a new technique of placement of the BariClip with additional gastric plication anterior, posterior, and volume reduction in the antrum to potentially reduce the rate of slippage and improve weight loss outcomes.
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Safety and Efficacy of Laparoscopic Vertical Clip Gastroplasty: Early Results of an Italian Multicenter Study
Article
Full-text available
  • Dec 2022
  • OBES SURG
PurposeSleeve gastrectomy, the most commonly performed bariatric surgery procedure, carries limitations both short term including postoperative complications such as hemorrhage and gastric fistula and long term such as weight regain and gastroesophageal reflux. A new procedure has been proposed to overcome many of these limitations: laparoscopic vertical clip gastroplasty (LVCG) with BariClip.Materials and Methods Fifty patients were offered LVCG and enrolled for a feasibility study in two referral bariatric centers. Indication was given as for sleeve gastrectomy, after a multidisciplinary path evaluating age, gender, BMI, comorbidities, eating behaviors, and gastroesophageal reflux. The primary outcome was major postoperative complications. Secondary outcomes included weight loss, incidence of de-novo GERD, and comorbidity resolution.ResultsPatients had a mean age of 44 years and mean BMI of 37 kg/m2 ± 6.2. All procedures were performed successfully in laparoscopy, with no conversion or intraoperative adverse events. The overall major postoperative complication rate was 6%. Re-operation was required in three patients for slippage. No mortality occurred. Excess weight loss, excess BMI loss, and total weight loss at 6 months were 36%, 57%, and 22%, respectively. There was no instance of de-novo GERD. Resolution of hypertension occurred in 50% of cases, OSAS in 65% of cases, and DMII in 80% of cases.Conclusion The safety of LVCG procedure has been reproduced in a multicentric, multi-surgeon study. Weight loss outcomes appear promising. A randomized trial is needed to fully assess the benefits of LVCG.Graphical Abstract
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The Reflux and BariClip: Initial Results and Mechanism of Action
Article
Full-text available
  • Nov 2022
Introduction: Laparoscopic BariClip Gastroplasty (LBCG) represents a new bariatric procedure that mimics the principle of the Laparoscopic Sleeve Gastrectomy (LSG), but using a completely reversible mechanism, which is essential for gastroesophageal reflux disease (GERD). The purpose of our study was to evaluate the evolution of GERD following the initial experience with LBCG. Methods: The first 43 obese patients who underwent LBCG performed by the same surgeon in two different medical centers in May 2018-December 2019 were included in the current study. Twelve patients had issues of reflux, regularly receiving PPIs (proton pump inhibitors) treatment in eight cases, and occasionally in four cases. Thirty-two patients completed the follow-up at one year and the GERD was evaluated using the PPI medications and the GerdQ. Results: The median preoperative GerdQ score was (14.58 ± 1.9). Three patients out of the twelve who had complained about preoperative GERD did not consent to the one year follow-up form. For the rest of nine patients, the median post-operative GerdQ score was (10.11 ± 3.2). The PPIs were used at one year follow-up in six patients: four with occasional use, one patient with regular use showing no improvement, and one who experienced de novo GERD symptomatology (3.1%). No statistically significant difference between the groups was recorded in terms of GERD. We recorded no intraoperative complications. No case of erosion occurred in the post-operative period, but we encountered two cases of slippage. One additional BariClip was removed at 14 months. Conclusion: LBCG represents a new bariatric procedure that mimics the principle of the laparoscopic sleeve gastrectomy, but with a completely reversible mechanism. Even with limited cases, our experience reports several mechanisms of action that will be evaluated and discussed in further prospective clinical trials. After this preliminary clinical study, LBCG's effects on GERD and its safety are highly encouraging.
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Safety of Endoscopic Sleeve Gastroplasty with a Single-Channel Endoscope
Article
Full-text available
  • Sep 2022
  • OBES SURG
Purpose Less invasive endoscopic bariatric procedures are under development for the management of class I of obesity. The purpose of our study is to evaluate the safety of endoscopic sleeve gastroplasty (ESG) using the new suturing device OverStitch Sx™. Materials and Methods This is a retrospective single-center study over 191 patients using the ESG under general anesthesia with overnight inpatient observation between January 2019 and December 2020. The analyzed variables were adverse effects and change in body weight at 6 and 12 months of follow-up. Results A total of 191 patients underwent ESG for primary obesity. There were 173 female (90.6%) with a mean age of 36.9 years. The mean BMI was 33.7 kg/m² (range: 28.9–54). There were no major intra-procedure adverse events. There were two postprocedural complications (1.04%), a transparietal suturing of falciform ligament which needed laparoscopic exploration for severe abdominal pain and a perigastric collection with antibiotic treatment, both with favorable outcome. Considering the weight loss results, the %TWL recorded was 22.4% for 84 patients (43.9%, 6 months’ follow-up) and 18.7% for 69 patients (36.1%, 12 months’ follow-up) with the mean EWL of 41.6% and respectively 34.7%. A total of 59 patients (30.9%) were lost follow-up and 12 patients underwent revisional bariatric procedure. According to ASGE definition, 53.8% (n = 71) reached > 25% of EWL. Conclusion Endoscopic gastroplasty represents a safe minimal invasive approach with the new device OverStitch Sx™ that can be considered an effective and well-tolerated procedure especially for primary obesity treatment. Graphical Abstract
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Volume and position change of the stomach during gastric accommodation and emptying: A detailed three‐dimensional morphological analysis based on MRI
Article
Full-text available
Background The proximal and distal regions of the stomach are thought to have different roles during gastric accommodation and emptying; however, regional changes in gastric structure and function during and after a meal have not been described in detail. This study applied non‐invasive imaging to study changes in regional gastric volume and morphology during accommodation and emptying of a liquid nutrient meal. Method MRI studies were performed on 16 healthy volunteers. Three‐dimensional (3D) gastric morphology was reconstructed by validated image processing technology. The 3D models were segmented into seven regions. The relative contribution of each region to gastric accommodation and emptying was assessed. Changes in morphology were documented by tracking movements of four distinct gastric landmarks. Key Results The initial 100 mL liquid nutrient increases distal stomach volume more than that of other gastric regions (∆V7 = 28 ± 6% ∆TGV; P ≤ .05). Subsequent volume is accommodated mainly in the proximal stomach (∆V1 = 42 ± 10% ∆TGV; P ≤ .05). Early‐phase emptying occurs from distal stomach with proximal stomach volume remaining stable. Subsequently, distal stomach volume remains stable while proximal stomach volume decreases progressively. During gastric filling, the stomach elongates and expands anteriorly and inferiorly (15.2 ± 7.4 mm and 32.3 ± 8.4 mm, respectively, for the incisural midpoint) with torsion indicated by ~70° difference in the movements of proximal and distal gastric landmarks. Conclusions and Inferences Non‐invasive MRI describes volume change and distribution of a liquid meal within proximal and distal stomach during gastric accommodation and emptying. Additionally, novel observations of changes to 3D gastric morphology within the abdomen are documented.
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Long-Term Outcomes After Bariatric Surgery: a Systematic Review and Meta-analysis of Weight Loss at 10 or More Years for All Bariatric Procedures and a Single-Centre Review of 20-Year Outcomes After Adjustable Gastric Banding
Article
Full-text available
  • Jan 2019
  • OBES SURG
Introduction Durability is a key requirement for the broad acceptance of bariatric surgery. We report on durability at and beyond 10 years with a systematic review and meta-analysis of all reports providing data at 10 or more years and a single-centre study of laparoscopic adjustable gastric banding (LAGB) with 20 years of follow-up. Methods Systematic review with meta-analysis was performed on all eligble reports containing 10 or more years of follow-up data on weight loss after bariatric surgery. In addition, a prospective cohort study of LAGB patients measuring weight loss and reoperation at up to 20 years is presented. Results Systematic review identified 57 datasets of which 33 were eligible for meta-analysis. Weighted means of the percentage of excess weight loss (%EWL) were calculated for all papers included in the systematic review. Eighteen reports of gastric bypass showed a weighted mean of 56.7%EWL, 17 reports of LAGB showed 45.9%EWL, 9 reports of biliopancreatic bypass +/− duodenal switch showed 74.1%EWL and 2 reports of sleeve gastrectomy showed 58.3%EWL. Meta-analyses of eligible studies demonstrated comparable results. Reoperations were common in all groups. At a single centre, 8378 LAGB patients were followed for up to 20 years with an overall follow-up rate of 54%. No surgical deaths occurred. Weight loss at 20 years (N = 35) was 30.1 kg, 48.9%EWL and 22.2% total weight loss (%TWL). Reoperation rate was initially high but reduced markedly with improved band and surgical and aftercare techniques. Conclusion All current procedures are associated with substantial and durable weight loss. More long-term data are needed for one-anastomosis gastric bypass and sleeve gastrectomy. Reoperation is likely to remain common across all procedures.
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Laparoscopic Vertical Clip Gastroplasty – Quality of life
Article
Full-text available
  • Jul 2018
  • SURG OBES RELAT DIS
Background Over the last decade, several techniques have emerged and the bariatric trends have changed. A new bariatric procedure that has been proposed is laparoscopic vertical clip gastroplasty (LVCG), which mimics the principle of laparoscopic sleeve gastrectomy, but with a completely reversible mechanism. The introduction of a new procedure in the bariatric armamentarium necessitated a period of preclinical and clinical studies and a validation of the procedure concerning the quality of life. Setting Private hospital, Dominican Republic. Objectives The purpose of this manuscript was to evaluate patient satisfaction, measured by various questionnaires after LVCG. Methods From November 2012 to February 2017, 138 patients underwent LVCG and demographic data were collected prospectively. A total of 82 were evaluated for quality of life with a minimum follow-up of 6 months after the procedure. The quality of life was also analyzed regarding the complications and resolution of different medical conditions included in the Bariatric Analysis and Reporting Outcome System score. Results Eighty-five patients (73.9%) agreed to participate in the study and a total of 82 patients completed the questionnaires at all points in time. Seventy-one patients were female, with an average age of 34 (19–38). Mean body mass index before operation was 42.4 kg/m² and declined significantly in both the first and second year postoperatively to 33.7 kg/m² (1-year follow-up) in 65 patients and 34.3 kg/m² (2-year follow-up) in 37 patients. The results showed failure for 1.2% of patients and were fair for 6.1% of cases. Quality of life was assessed as good for 26 patients (31.8%), as very good for 39 patients (47.5%), and as excellent for 11 patients (13.4%). Conclusions LVCG represents a new bariatric procedure that mimics the principle of laparoscopic sleeve gastrectomy, but with a completely reversible mechanism. The procedure consists of a nonadjustable clip that is vertically placed parallel to the lesser curvature. After >3 years of clinical use, the weight loss results seem to be encouraging and up to 92.7% of patients have an improved quality of life.
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A Vertically Placed Clip for Weight Loss: a 39-Month Pilot Study
Article
Full-text available
  • May 2017
  • OBES SURG
Background: Morbid obesity remains one of society's significant medical dilemmas. It is rapidly worsening and expected to affect 35% of the US population by the year 2020. Common current bariatric procedures exist and include, but not limited to, the adjustable gastric band, gastric bypass, and the sleeve gastrectomy. Although beneficial to morbidly obese patients, they also alter the patient's anatomy and involve resections, or require maintenance. The goal of the trial is to show a new minimally invasive vertical gastric clip technique that produces significant weight loss but requires no resection, no change in anatomy, and is reversible. Methods: From November 2012 to February 2016, prospective collected data from 117 patients was included in the gastric clip trial. The clip consists of a silicone-covered titanium backbone with an inferior hinged opening that separates a medial lumen from an excluded lateral gastric pouch. The inferior opening allows the gastric juices to empty from the fundus and the body of the stomach into the distal antrum. Results: Weight loss and comorbidities were evaluated among 117 patients over a 39-month period. 66.7% excess weight loss was seen with minimal adverse events. Average length of surgery was 69 min. Average length of stay was 1.3 days. Fifteen of the originally implanted clips were electively removed based on the original protocol, and the other two were removed for displacement of the device. Conclusion: The vertical, gastric clip trial has shown that excellent weight loss can be achieved without some of the complications seen with historical bariatric procedures. This clip is placed without requiring stapling, resection, malabsorption, change in anatomy, or maintenance. It is also easily reversible.
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Reoperations After Bariatric Surgery in 26 Years of Follow-up of the Swedish Obese Subjects Study
Article
  • Jan 2019
Importance Bariatric surgery is an established treatment for obesity, but knowledge on the long-term incidence of revisional surgery is scarce. Objective To determine the incidence and type of revisional surgery after bariatric surgery in 26 years of follow-up of participants in the Swedish Obese Subjects (SOS) study. Design, Setting, and Participants The SOS study is a prospective nonrandomized controlled study comparing bariatric surgery (banding, vertical banded gastroplasty [VBG], and gastric bypass [GBP]) with usual care. The bariatric surgeries in the SOS study were conducted at 25 public surgical departments in Sweden. Men with body mass index values of 34 or higher and women with body mass indexes of 38 or higher were recruited to the surgery group of the SOS study between September 1, 1987, and January 31, 2001, and follow-up continued until December 31, 2014. Data analysis occurred from November 2016 to April 2018. Interventions Banding, VBG, or GBP. Main Outcomes and Measures Revisional surgeries, analyzed using data from questionnaires, hospital records, and the Swedish National Patient register through December 31, 2014. Results A total of 2010 participants underwent surgery. The age range was 37 to 60 years. A total of 376 participants underwent banding (18.7%), while 1365 had VBG (67.9%) and 266 had GBP (13.2%). During a median follow-up of 19 years, 559 participants (27.8%) underwent first-time revisional surgery, including 354 conversions to other bariatric procedures (17.6%), 114 corrective surgeries (5.6%), and 91 reversals to normal anatomy (4.5%). Revisional surgeries (conversions, corrective surgery, and reversals) were common after banding (153 of 376 [40.7%]) and VBG (386 of 1365 [28.3%]) but relatively rare after GBP (20 of 266 [7.5%]). Patients who had banding and VBG primarily underwent conversions to GBP or reversals. Incidence of reversals was 5 times higher after banding than after VBG (40.7% vs 7.5%; unadjusted hazard ratio, 5.19 [95% CI, 3.43-7.87]; P < .001). Corrective surgeries were equally common irrespective of the index surgery (72 of 1365 patients who had VBG [5.3%]; 23 of 376 patients who had banding [6.1%]; 19 of 266 patients who had GBP [7.1%]). Revisional surgery indications, including inadequate weight loss, band-associated complications (migration, stenosis, and slippage), staple-line disruptions, and postsurgical morbidity, varied depending on index surgery subgroup. Most corrections occurred within the first 10 years, whereas conversions and reversals occurred over the entire follow-up period. Conclusions and Relevance Corrective surgeries occur mainly within the first 10 years and with similar incidences across all 3 surgical subgroups, but indications varied. Conversions (mainly to GBP) and reversals occurred after many years and were most frequent after banding and VBG, reflecting a higher overall revisional surgery demand after these operations.
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