scholarly journals Endoscopic sleeve gastroplasty versus intragastric balloon insertion: efficacy, durability, and safety

Endoscopy ◽  
2019 ◽  
Vol 51 (06) ◽  
pp. 532-539 ◽  
Author(s):  
Lea Fayad ◽  
Lawrence J. Cheskin ◽  
Atif Adam ◽  
Dilhana S. Badurdeen ◽  
Christine Hill ◽  
...  
Keyword(s):  
Weight Loss ◽  
Body Weight ◽  
Adverse Events ◽  
Intragastric Balloon ◽  
Body Weight Loss ◽  
Total Body Weight ◽  
Baseline Body Mass Index ◽  
Endoscopic Sleeve Gastroplasty ◽  
Post Procedure ◽  
Sleeve Gastroplasty

Abstract Background Intragastric balloon (IGB) placement and endoscopic sleeve gastroplasty (ESG) are reported to be safe and effective endoscopic bariatric therapies. This study aimed to compare the patient demographics and therapeutic outcomes between the IGB and ESG procedures. Methods: This was a retrospective review of prospectively collected data from consecutive patients between December 2015 and October 2017 who underwent IGB or ESG at a single academic center. Fluid-filled IGBs implanted for a 6-month duration were used. IGB and ESG patients were subjected to identical post-procedure dietary instructions and follow-up protocols. Body weight was recorded at 1, 3, 6, and 12 months post-procedure. Results A total of 47 patients underwent IGB insertion and 58 underwent ESG. The IGB cohort had a lower baseline body mass index (BMI) than the ESG (34.5 vs. 41.5 kg/m2; P < 0.001) and a significantly lower proportion of men (2.1 % vs. 41.4 %; P < 0.001). IGB patients showed a mean (standard deviation [SD]) percentage total body weight loss (%TBWL) that was significantly lower than ESG patients at 1 month (6.6 % [2.6 %] vs. 9.9 % [2.4 %]; P < 0.001), 3 months (11.1 % [4.4 %] vs. 14.3 % [4.6 %]; P = 0.004), 6 months (15.0 % [7.6 %] vs. 19.5 % [5.7 %]; P = 0.01), and 12 months (13.9 % [9.0 %] vs. 21.3 % [6.6 %]; P = 0.005). The IGB cohort also experienced significantly more adverse events compared with the ESG (17 % vs. 5.2 %; P = 0.048). Conclusions IGB placement and ESG result in clinically meaningful weight loss. However, ESG appears to provide clinically superior and more enduring weight loss with fewer adverse events compared with an IGB.

scholarly journals Endoscopic sleeve gastroplasty: a modified technique with greater curvature compression sutures

2019 ◽  
Vol 07 (10) ◽  
pp. E1303-E1309 ◽  
Author(s):  
Michael A. Glaysher ◽  
Alma L. Moekotte ◽  
Jamie Kelly
Keyword(s):  
Weight Loss ◽  
Body Weight ◽  
Effective Means ◽  
Body Weight Loss ◽  
Total Body Weight ◽  
Modified Technique ◽  
Longitudinal Compression ◽  
Median Baseline ◽  
Endoscopic Sleeve Gastroplasty ◽  
Sleeve Gastroplasty

Abstract Background Endoscopic sleeve gastroplasty (ESG) is rapidly becoming established as a safe and effective means of achieving substantial weight loss via the transoral route. New ESG suture patterns are emerging. Our aim was to investigate whether superior weight loss outcomes can be achieved by using a unique combination of longitudinal compression sutures and “U”-shaped sutures. Methods This is a retrospective review of prospectively collected data of all patients undergoing ESG by a single operator in a single UK center. Results Between January 2016 and December 2017, 32 patients (23 female) underwent ESG; n = 9 cases were completed utilizing a commonly used triangular suture pattern (“no longitudinal compression”) and n = 23 cases were completed using our unique “longitudinal compression” suture pattern. In the no compression and compression groups, the mean ages were 45 ± 12 years and 43 ± 10 years, the median baseline weights were 113.6 kg (range 82.0 – 156.4) and 107 kg (range 74.0 – 136.0), and the median baseline body mass indexes (BMIs) were 35.9 kg/m2 (range 30.9 – 43.8) and 36.5 kg/m2 (range 29.8 – 42.9), respectively. After 6 months, body weight had decreased by 21.1 kg (range, 12.2 – 34.0) in the compression group (n = 7) versus 10.8 kg (range, 7.0 – 25.8) in the no compression group (n = 5) (P = 0.042). Correspondingly, BMI decreased by 7.8 kg/m2 (range, 4.9 – 11.2) and 4.1 kg/m2 (range, 2.6 – 7.2) in each group, respectively (P = 0.019). Total body weight loss (%TBWL) was greater in the compression group at 19.5 % (range, 12.9 – 30.4 %) compared to 13.2 % (range, 6.2 – 17.1 %) in the non-compression group (P = 0.042). No significant adverse events were reported in this series. Conclusion The technique of ESG is evolving and outcomes from endoscopic bariatric therapies continue to improve. We provide preliminary evidence of superior weight loss achieved through a modified gastroplasty suture pattern.

Initial experience with endoscopic sleeve gastroplasty in Poland

2018 ◽  
Vol 90 (2) ◽  
pp. 16-22 ◽  
Author(s):  
Aleksander Sowier ◽  
Przemysław Pyda ◽  
Anna-Maria Borucka ◽  
Sebastian Sowier ◽  
Jacek Białecki ◽  
...  
Keyword(s):  
Weight Loss ◽  
Body Weight ◽  
Sleeve Gastrectomy ◽  
Laparoscopic Sleeve Gastrectomy ◽  
Body Weight Loss ◽  
Total Body Weight ◽  
Sleeve Resection ◽  
Less Invasive ◽  
Endoscopic Sleeve Gastroplasty ◽  
Sleeve Gastroplasty

Introduction: Obesity is becoming one of the major public health problems. Bariatric procedures are considered the most effective methods of treating this condition but they are costly and entail a high risk of complications. Thus, there is a need to look for better bariatric treatment solutions. One of the newest, highly promising bariatric methods is endoscopic sleeve gastroplasty (ESG), which is comparably effective to other bariatric procedures in terms of weight loss but at the same time it is much less invasive. Materials and methods: Eight obese patients underwent ESG. Under general anaesthesia, an endoscope was inserted into the stomach, where a row of 4-5 running stitches was placed (from the pyloric part towards the GE junction). Each of the stitches was cinched tight, which resulted in gastric lumen reduction comparable to that achieved with laparoscopic sleeve gastrectomy. Results: The procedures were performed without any severe peri-operative complications. The only adverse event was a minor haemorrhage in one of the patients, which did not require any surgical intervention. After the surgery, the patients reported a substantial weight loss. Mean %TBWL was 8.6%, 15.4% and 19.6% at 1, 2 and 3 months, respectively. Conclusions: Minimally invasive and highly effective in body weight reduction, endoscopic sleeve gastroplasty is a promising method of treating obesity. The procedure requires appropriate tools and equipment. The method guarantees gastric volume reduction comparable to that achieved with sleeve resection. The initial results confirm that the effectiveness of the surgery in terms of body weight loss is similar to that seen in other forms of bariatric treatment. Discussion: Compared to laparoscopic sleeve gastrectomy, endoscopic sleeve gastroplasty is substantially less invasive. Also, it requires shorter procedure time and shorter hospital stay. Data from other medical centres demonstrate somewhat lower dynamics of total body weight loss but these results need to be verified in a long-term follow-up.

scholarly journals Redo endoscopic sleeve gastroplasty: technical aspects and short-term outcomes

2020 ◽  
Vol 13 ◽  
pp. 175628481989617 ◽  
Author(s):  
Ivo Boškoski ◽  
Valerio Pontecorvi ◽  
Camilla Gallo ◽  
Vincenzo Bove ◽  
Lucrezia Laterza ◽  
...  
Keyword(s):  
Weight Loss ◽  
Case Series ◽  
Body Weight Loss ◽  
Total Body Weight ◽  
Baseline Body Mass Index ◽  
Short Term ◽  
Technical Aspects ◽  
Endoscopic Sleeve Gastroplasty ◽  
Sleeve Gastroplasty

Background: Endoscopic sleeve gastroplasty (ESG) is a restrictive endoscopic bariatric procedure providing promising results. In this short case series, we analyze the technical aspects and short-term outcomes of the redo ESG. Methods: A retrospective analysis was done on a prospective database of all patients that were selected by a multidisciplinary team that underwent ESG between March 2017 and May 2019. Patients that underwent a redo ESG because of a progressive loss of satiety, weight regain, or insufficient weight loss due to high baseline body mass index were included. Percentage of excess weight loss (%EWL), percentage of total body weight loss (%TBWL), and the Bariatric Analysis and Reporting Outcome System (BAROS) questionnaire were evaluated during follow-up. Results: A total of 120 ESG procedures were performed with mean %EWL of 44.4% (± 19.5), mean %TBWL of 18.3% (± 6.7), and mean BAROS of 4.5 (± 1.7) at 12 months. Of those, four patients that underwent a redo ESG were identified. A total of three of them had a redo ESG after 12 months from the first ESG, whereas one of them had a redo ESG after 7 months. During the second procedure, old threads were removed with scissors and new stitches were positioned following a triangular pattern and avoiding overlap with the previous stitches. No adverse events were reported during the redo ESG. Six month follow-up was available for three patients, mean %EWL and %TBWL were 44.2% and 20.4%, respectively; BAROS questionnaire mean score was 6.3. One patient had only 1 month follow-up with a mean %EWL and %TBWL of 33.3% and 12.2%, respectively; BAROS questionnaire reported score was 6. All included patients reported excellent satiety feeling after redo ESG. Conclusions: The redo ESG short-term outcomes are completely satisfying in terms of safety and efficacy. The need to perform a redo ESG should not be considered as a failure of the previous procedure, but it can be considered as a second step of the endoscopic treatment strategy.

Initial experience with endoscopic sleeve gastroplasty in Poland

2018 ◽  
Vol 90 (4) ◽  
pp. 6-11 ◽  
Author(s):  
Przemysław Pyda ◽  
Aleksander Sowier ◽  
Sebastian Sowier ◽  
Anna-Maria Borucka ◽  
Joanna Kapturzak ◽  
...  
Keyword(s):  
Weight Loss ◽  
Body Weight ◽  
Sleeve Gastrectomy ◽  
Laparoscopic Sleeve Gastrectomy ◽  
Body Weight Loss ◽  
Total Body Weight ◽  
Sleeve Resection ◽  
Less Invasive ◽  
Endoscopic Sleeve Gastroplasty ◽  
Sleeve Gastroplasty

Introduction: Obesity is becoming one of the major public health problems. Bariatric procedures are considered the most effective methods of treating this condition but they are costly and entail a high risk of complications. Thus, there is a need to look for better bariatric treatment solutions. One of the newest, highly promising bariatric methods is endoscopic sleeve gastroplasty (ESG), which is comparably effective to other bariatric procedures in terms of weight loss but at the same time it is much less invasive. Materials and methods: Eight obese patients underwent ESG. Under general anaesthesia, an endoscope was inserted into the stomach, where a row of 4-5 running stitches was placed (from the pyloric part towards the GE junction). Each of the stitches was cinched tight, which resulted in gastric lumen reduction comparable to that achieved with laparoscopic sleeve gastrectomy. Results: The procedures were performed without any severe peri-operative complications. The only adverse event was a minor haemorrhage in one of the patients, which did not require any surgical intervention. After the surgery, the patients reported a substantial weight loss. Mean %TBWL was 8.6%, 15.4% and 19.6% at 1, 2 and 3 months, respectively. Conclusions: Minimally invasive and highly effective in body weight reduction, endoscopic sleeve gastroplasty is a promising method of treating obesity. The procedure requires appropriate tools and equipment. The method guarantees gastric volume reduction comparable to that achieved with sleeve resection. The initial results confirm that the effectiveness of the surgery in terms of body weight loss is similar to that seen in other forms of bariatric treatment. Discussion: Compared to laparoscopic sleeve gastrectomy, endoscopic sleeve gastroplasty is substantially less invasive. Also, it requires shorter procedure time and shorter hospital stay. Data from other medical centres demonstrate somewhat lower dynamics of total body weight loss but these results need to be verified in a long-term follow-up.

scholarly journals Sa1949 A SIMPLE FLUOROSCOPIC SCORE IMMEDIATELY AFTER ENDOSCOPIC SLEEVE GASTROPLASTY PREDICTS TOTAL BODY WEIGHT LOSS

2020 ◽  
Vol 91 (6) ◽  
pp. AB218-AB219
Author(s):  
Kaveh Hajifathalian ◽  
Andrea S. Kierans ◽  
Shawn L. Shah ◽  
Amit Mehta ◽  
Angela Wong ◽  
...  
Keyword(s):  
Weight Loss ◽  
Body Weight ◽  
Body Weight Loss ◽  
Total Body Weight ◽  
Endoscopic Sleeve Gastroplasty ◽  
Sleeve Gastroplasty ◽  
Total Body ◽  
Total Body Weight Loss

scholarly journals Endoscopic Sleeve Gastroplasty for Obesity – First Indian Experience: Case Series and Review of Literature

2018 ◽  
Vol 09 (04) ◽  
pp. 165-167
Author(s):  
Nitin Jagtap ◽  
Rakesh Kalapala ◽  
Abhishek Katakwar ◽  
Santosh Darishetty ◽  
D Nageshwar Reddy
Keyword(s):  
Weight Loss ◽  
Adverse Events ◽  
Case Series ◽  
Body Weight Loss ◽  
Total Body Weight ◽  
Procedural Time ◽  
Sleeve Gastroplasty ◽  
Total Body ◽  
Total Body Weight Loss

ABSTRACT Introduction: In India, obesity affects >135 million and leads to nearly 5.8 million deaths per year. Some of the unmet need in the management of obesity can be fulfilled by endoscopic therapies such as endoscopic sleeve gastroplasty (ESG). Methods: In this case series, we report our preliminary experience of ESG in three obese patients. We recorded baseline demographic data, total procedural time, adverse events, and percentage total body weight loss (%TBWL) up to 20 weeks. Results: All three patients were male with a median age of 29 years (range 26–39) with a median body mass index of 34.28 kg/m2 (range 32.60–37.13). A total of four full‑thickness and additional three submucosal sutures were applied in each patient. There were no adverse events. The median total procedural time was 105 min (range 90–150). All patients were discharged within 48 h. The median percentage total body weight loss (%TBWL) at 12 weeks was 12.02 (range 10.85–13.33) and at 16 weeks was 14.23 (range 13.84–14.62). The maximum follow‑up so far is 20 weeks (one patient) with %TBWL of 16.38. Conclusion: In our preliminary experience, we conclude that ESG is safe, effective and requires shorter hospital stay. In short‑term follow‑up, there is adequate weight loss without major adverse events.

Adjustable gastric balloons for weight loss – a higher yield of responders compared to non-adjustable gastric balloons

2020 ◽  
Vol 74 (6) ◽  
pp. 513-519
Author(s):  
Adam Vašura ◽  
Evžen Machytka ◽  
Valenti Puig-Divi ◽  
Fernando Saenger ◽  
Ricardo Sorio ◽  
...  
Keyword(s):  
Weight Loss ◽  
Body Weight ◽  
Intragastric Balloon ◽  
Body Weight Loss ◽  
Total Body Weight ◽  
Gastric Ulcers ◽  
Excess Body Weight ◽  
Duration Of Effect ◽  
Extra Weight ◽  
Weight Loss Plateau

Introduction: The degree of efficacy and duration of effect of the intragastric balloon (IGB) can be variable and unpredictable. The Spatz Adjustable Intragastric balloon (AIGB) was developed to extend implantation to 1 year, decrease the balloon volume for intolerance and increase the volume for a diminishing effect. The utility/efficacy and responder rate with the Spatz3 AIGB were the subjects of this study. Methods: The results of 227 consecutive patients, without exclusions, in 3 centres implanted with the Spatz3 AIGB were reviewed retrospectively. Mean BMI 35.9; mean weight 99.6 kg; mean Excess Body Weight Loss (EBWL) 30.6%; mean balloon volume 464ml (400–500 ml). Balloon volume adjustments were offered: downward adjustments for intolerance and upward adjustments for weight loss plateau. Results: 227 patients were implanted (mean 10.3 months) yielding a mean weight loss of 15.8 kg; mean 15.7% Total Body Weight Loss (TBWL) and 57.6% Excess Body Weight Loss (EBWL). Response (> 25% EBWL) was achieved in 83.3% of the patients. Downward adjustments in 15 patients (mean 2.3 weeks; mean –120 ml) allowed 12/15 (80%) to continue IGB therapy for a mean of 8.8 months. Upward adjustments in 107 patients (mean of 4.7 months; mean +284ml) yielded an additional mean weight loss of 8.5 kg. The upward-adjusted group at extraction had a mean weight loss of 17.8 kg; 17.2% TBWL and 59.2% EBWL. Two gastric ulcers: one due to NSAIDs and one healed with downward adjustment. Conclusions: In this retrospective review of 227 consecutive Spatz3 AIGB patients, upward adjustments yielded a mean 8.5 kg extra weight loss for those with a weight loss plateau, and downward adjustments alleviated early intolerance in 80% of the patients. These two adjustment functions may be instrumental in yielding a response rate of 83.3%

scholarly journals ENDOSCOPIC SLEEVE GASTROPLASTY FOR OBESITY TREATMENT: TWO YEARS OF EXPERIENCE

2017 ◽  
Vol 30 (1) ◽  
pp. 18-20 ◽  
Author(s):  
Gontrand LOPEZ-NAVA ◽  
M P GALVÃO ◽  
I BAUTISTA-CASTAÑO ◽  
J P FERNANDEZ-CORBELLE ◽  
M TRELL ◽  
...  
Keyword(s):  
Weight Loss ◽  
Body Weight ◽  
Multidisciplinary Team ◽  
Body Weight Loss ◽  
Obesity Treatment ◽  
Excess Body Weight ◽  
Endoscopic Techniques ◽  
Endoscopic Sleeve Gastroplasty ◽  
Sleeve Gastroplasty

ABSTRACT Background: Bariatric endoscopic techniques are minimally invasive and induce gastric volume reduction to treat obesity. Aim: To evaluate endoscopic sleeve gastroplasty (Apollo method) using a suturing method directed at the greater curvature, as well as the perioperative care, two year safety and weight loss. Method: Prospective single-center study over 154 patients (108 females) using the endoscopic sleeve gastroplasty procedure under general anesthesia with overnight inpatient observation. Of the154 initial patients, 143 were available for 1-month of follow-up, 133 for 6-month, 64 for 12-month and 28 completed the 24 month assessment. Follow-up was carried out by a multidisciplinary team (nutritionist and psychologist). Outcomes evaluated were: change in BMI; change in body weight (TBWL); % of loss of initial body weight (%TBWL); % of excess body weight loss (%EWL) (segregated in > or <25% and adverse effects. Voluntary oral contrasted radiological examinations were scheduled to assess the gastroplasty at different times post-procedure. Results: Mean age was 44.9 (23-69) years. At 24 months after the procedure baseline mean BMI change from 38.3 to 30.8 kg/m2. TBWL, %TBWL and %EWL were of 21.3 kg, 19.5% and 60.4% respectively. 85.7% of patients achieve the goal of >25% %EWL. There were no mayor adverse events intraprocedure or during the 24 months of follow-up . Conclusion: Endoscopic sleeve gastroplasty with regular monitoring by a multidisciplinary team can be considered an effective, safe and well tolerated procedure for obesity treatment, at least for two years of follow-up.

scholarly journals SUN-543 Real World Evidence of Successful Weight Management for the Obese Population: Complete Reversal of Obesity Related Metabolic Co-Morbidities and Weight Loss in Patients Attending a Multidisciplinary Weight Management Clinic in Australia

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Zoe Rock ◽  
Juliana Chen ◽  
Joanna Jaques ◽  
Bernard L Champion ◽  
Reginald V Lord ◽  
...  
Keyword(s):  
Weight Loss ◽  
Body Weight ◽  
Weight Management ◽  
Exercise Physiology ◽  
Body Weight Loss ◽  
Total Body Weight ◽  
Management Interventions ◽  
Co Morbidity ◽  
Total Body ◽  
Total Body Weight Loss

Abstract Over 2.5 billion people worldwide are overweight or obese. Multidisciplinary weight management interventions have evolved to address the complexity of weight loss for those with one or more chronic diseases, and the trend of weight regain. The aim of these interventions is to encourage sustainable lifestyle changes, resulting in weight loss and weight maintenance and improvements in comorbidities. While some prospective clinical trials have demonstrated efficacy, results are often not reported by real life practices. The aim of this study was to evaluate the effectiveness of a Sydney based multidisciplinary weight management clinic with endocrinology, dietetics, exercise physiology, psychology, and bariatric surgical domains. All patients who attended the clinic for weight loss purposes between March 2017 and April 2019 were included (n=220). A retrospective chart review was conducted. Patient data on weight, BMI, waist circumference, body composition measurements, and selected blood test results and co-morbidities were analysed. All patient therapy included endocrinological input for co-morbidity identification and management, lifestyle intervention (dietetic and exercise physiology input) with optional adjunct pharmacotherapy or psychological counselling. Of the 220 cohort, 20 of the patients had sleeve gastrectomy. Patient retention in the clinic after the first consultation was 85% (n=186), a high rate within the weight management community. 59% of patients achieved a minimum of 5% total body weight loss, including 18% who achieved greater than 10% total body weight loss. Additionally, 31% of patients lost enough weight to decrease their BMI class by up to 2 or more classes. Of the gastric sleeve cohort average excess body weight loss was 32kg (21-56kg) enhanced by multidisciplinary care in the lead up to surgery. Across the cohort some patients completely reversed co-morbidities; including dyslipidaemia (n=1), hypertension (n=3), NAFLD (n=1), pre-diabetes (n=8) and type 2 diabetes (n=3), OSA (n=1). These results demonstrate that obesity is a chronic condition that can be successfully managed. We have demonstrated significant durable weight loss and improvement in metabolic co-morbidities with holistic coordinated care. Future directions include translating this model of care into standard practice in Australia and other countries where obesity to date not received the same coordinated approach as other chronic conditions.

scholarly journals Suture pattern does not influence outcomes of endoscopic sleeve gastroplasty in obese patients

2020 ◽  
Vol 08 (10) ◽  
pp. E1349-E1358
Author(s):  
E. Espinet-Coll ◽  
J. Nebreda-Durán ◽  
M. Galvao-Neto ◽  
C. Bautista-Altamirano ◽  
P. Diaz-Galán ◽  
...  
Keyword(s):  
Weight Loss ◽  
Body Weight Loss ◽  
Total Body Weight ◽  
Obese Patients ◽  
Serious Adverse Events ◽  
Comparative Review ◽  
Sleeve Gastroplasty ◽  
Total Body ◽  
Suture Patterns ◽  
Comorbidity Resolution

Abstract Background and study aims ESG is an effective and safe medium-term procedure for obesity treatment. A variety of suture patterns have been reported. We aimed to compare whether there are differences in efficacy depending on suture pattern used. Patients and methods Retrospective and comparative review of 5 years of prospectively collected data, including consecutive obese patients undergoing ESG at two collaborative centers. Primary outcomes included weight loss (mainly % total body weight loss [TBWL] and % exces weight loss [EWL]) at 12 months and safety profile. We compared them according to three suture patterns (transverse bilinear [TBp], longitudinal [Lp] and transverse monolinear [TMp]), and number of sutures (4 – 7) and stitches (< 25, 25 to 30 and > 30) applied. Evolution of major obesity-associated morbidities (hypertension, dyslipidemia, Type 2 diabetes mellitus (T2DM), sleep obstructive apnea syndrome, and arthropathy) were also described. Results 88 patients (mean age 46.1±12.3 years, 69.3 % female) underwent ESG. Mean body mass index (BMI) at baseline was 39.40 ± 4.69 kg/m². At 1 year, %TBWL was 17.36 ± 6.09 % (%EWL 46.41±20.6 %) with TBWL > 10 % in 95.5 % of patients (EWL > 25 % in 94.3 % of patients). According to pattern, there were no differences in %TBWL but there were in %EWL (43.7 ± 20.4 %, 59.8 ± 18.9 % and 45.4 ± 14.9 % in TBp, Lp and TMp patterns, respectively) (P = 0.034). No differences were found related to number of sutures (mean 5.2 ± 0.73, r = 4 – 7) or stitches (mean 27.4 ± 6.50, r = 18 – 50) applied. Forty-three of 72 (59.7 %) major comorbidities were resolved. No serious adverse events were observed with any pattern. Conclusions ESG is an effective procedure at 12-month follow-up for weight loss and comorbidity resolution. All three analyzed patterns are safe and effective without differences in %TBWL, but there was a slight increase in %EWL in Lp, regardless of the number of sutures or stitches applied.

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