Vertical Gastroplasty with Artificial Pseudopylorus: A Modification in the Treatment of Morbid Obesity. Early Results

A new technique of vertical gastroplasty was applied in 50 morbidly obese patients. Eight of them were male and 42 female with a mean age of 34 years (range 20-58). The mean excess body weight was 77 kg (range 52-133) and the mean Body Mass Index 51 kg/m² (range 42-81). Under direct vision the hepatogastric and gastrophrenic ligaments were divided and two TA-90 double-row staplers were passed together through the lesser sac vertically downwards from His angle parallel to the lesser curvature of the stomach. An additional TA-90 stapler was applied between the two double rows. The pseudopylorus was constructed 3-4 cm below the stomach angle by the use of two bands of silk No. 0 which were covered by stomach serosa, thus creating a reinforced outlet having the shape of a pylorus which we called ‘artificial pseudopylorus’. The circumference of pseudopylorus was 4.8 cm and the total volume of the vertical pouch of stomach 15-20 ml. The percentage excess weight loss on the 3rd, 6th, 12th, 18th and 24th month postoperatively was 35, 51, 68, 80, and 82 respectively. One patient died 12 days after operation. One other patient was re-operated because of staple-line breakdown and acute abdomen formation. It is concluded that vertical gastroplasty with artificial pseudopylorus is a simple and safe method that avoids complications of other forms of gastroplasty, and is of value in the treatment of morbidly obese patients.     

Long-Term Follow-up after Gastric Surgery for Morbid Obesity: Preoperative Weight Loss Improves the Long-Term Control of Morbid Obesity after Vertical Banded Gastroplasty

Background: Gastric restrictive surgery in a large non-university teaching hospital has been combined with preoperative weight loss by diet. The aims of preoperative dieting were to test patient motivation, to reduce perioperative morbidity, to accustom patients to the restriction of food intake after surgery, and to increase total weight loss. This study was performed to investigate the long-term results of this approach. Methods: 200 morbidly obese persons were operated on between 1978 and 1986 after they had lost more than 50% of their excess weight by diet. 100 Roux-en-Y gastric bypasses (RYGB) and, after 1983, 100 vertical banded gastroplasties (VBG) were performed. Data from medical records and data concerning present weight, complaints, food intolerance, nutritional deficiencies, and medical follow-up visits were obtained by questionnaire. Results: The lowest body weight was obtained 1 year after operation with an average excess weight loss (EWL) of 78% after RYGB and 75% after VBG. Body weight gradually increased, and 7 years after surgery the average EWL was 67% after RYGB and 63% after VBG. Ten patients had died (three postoperatively after RYGB). Preoperative dieting did not decrease perioperative morbidity and mortality in comparison with other reports. Conclusions: After combined preoperative dieting and VBG, weight loss is greater than after surgery alone. No additional weight loss after preoperative dieting was observed in RYGB patients. Most patients who underwent bariatric surgery still experience nutritional, physical, and cosmetic problems 7 years after surgery.     

Results of Vertical Banded Gastroplasty for Treatment of Morbid Obesity

The results of vertical banded gastroplasty were studied in 40 morbidly obese patients from 1 to 6 years after operation. The mean weight loss in this period varied from 37 to 45 kg and the Quetelet index from 28 to 32 kg/m². In 30% of the patients the individual weight loss is less than 25%. However, about 90% of the patients expressed satisfaction with the operation result. The early and late mortality was zero. The most common complications were wound infections and incisional hernias. Vertical banded gastroplasty is a safe operation, which gave a good or satisfactory result in 70% of the patients.     

Psychological Profile and Outcome in Patients Undergoing Gastroplasty for Morbid Obesity

Eighteen out of 22 consecutive patients undergoing vertical banded gastroplasty were reviewed with regard to preoperative psychological assessment and postoperative outcome. Each patient was initially evaluated by a consultant liaison psychiatrist with regard to previous or ongoing psychological disturbance, and suitability for bariatric surgery. Patients could be grouped into three broad categories: Group A (seven patients) those with no psychiatric abnormality; Group B (six patients) those with minor psychiatric disorders such as sociopathic teenage behaviour, outpatient treatment for depression; and Group C (five patients) those with a history of major psychiatric disturbance such as depressive psychosis and drug dependency. Psychiatric morbidity had no adverse effect in terms of postoperative outcome or weight loss. Mean weight loss of 26%, 30% and 33% was recorded in groups A, B and C respectively after a mean follow-up period of 33 months following gastroplasty. The occurrence of postoperative psychiatric problems correlated closely with preoperative psychological assessment, with none of seven patients in group A but four of the five patients in group C requiring psychiatric management. Our findings indicate that psychiatric illness is not associated with poor outcome following surgery for morbid obesity and such patients should not be excluded if psychiatric support is available before and after surgery.     

Vertical Banded Gastroplasty with Adjustable Silicone Band: Preliminary Experiences

A series of ten patients operated on with vertical banded gastroplasty (VBG) with an adjustable silicone band at the outlet is presented. The loss of body weight and complication rate is evaluated. Preoperative mean excess overweight of the patients was 94% and mean BMI was 42.6. The loss of body weight at one year's follow-up was 38 kg or 59% of excess weight. Complications were one case of infection at the subcutaneous injection port and one case of a nonfatal pulmonary embolus. The results so far are thus comparable with VBG with a conventional fixed band, but the adjustable band actually simplifies the operative procedure since no exact calibration of the collar size is necessary at the time of surgery and should diminish the need for reoperations due to misalignment of collar size. The possibility of better weight control in the long-term perspective remains to be proven.     

Technical Points in Vertical Gastroplasty for Morbid Obesity

The success of vertical gastroplasty may be jeopardized by gastric leakage or ulceration due to failure of the technique. Reports of band erosion and staple-line leakage have led us to seek technical improvements to reduce technical failures. We describe a modification to the technique of band placement and a manoeuvre to aid the placement of staples when the TA90 staple gun is used.     

Obesity Surgery Results Depending on Technique Performed: Long-Term Outcome

Background  Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. Methods  This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). Results  One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. Conclusions  The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75–225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m²), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.     

Biochemical Changes after Vertical Banded Gastroplasty for Morbid Obesity

A prospective study of biochemical changes after vertical banded gastroplasty for morbid obesity, in 94 patients (10 males and 84 females, ages ranging from 18 to 59 years) has been carried out. Liver function tests and electrolyte estimations were performed preoperatively, during hospitalisation for surgery, at 6 weeks and at 6 months postoperatively, and demonstrated no significant changes in liver function in these patients 6 months after surgery. The study concludes that there is no increase in the risk of liver damage or electrolyte disturbance after vertical gastroplasty, but that there may be subtle hepatic changes present as gall bladder disease developed in 18 patients postoperation (19%).     

Stoma Adjustable Silicone Gastric Banding versus Vertical Banded Gastroplasty for the Treatment of Morbid Obesity

Background: Among gastric restrictive operations, the procedure of choice is still controversial. The aim of this study is to compare the results of two different gastric restrictive procedures: vertical banded gastroplasty (VBG) and stoma adjustable silicone gastric banding (ASGB). Methods: Between 1991 and 1996, 51 patients were treated surgically for morbid obesity: 27 underwent VBG and 24 underwent ASGB. Preoperative body weight (BW), body mass index (BMI) and percentage of ideal body weight (% IBW) were (mean ± SD): 145.7 ± 45.3 kg; 53.9 ± 15.9 kg/m²; 249.1 ± 73.5% respectively in the VBG group. Corresponding figures for the ASBG group were 132.5 ± 22.7 kg; 46.9 ± 7.8 kg/m² and 207.2 ± 35.0%. Results: In the VBG group, the median follow-up period was 26 months (range: 7-47). Eighteen months after the operation BW, BMI, % IBW and percentage of excess weight loss (% EWL) were 85.5 ± 26.8 kg, 31.9 ± 9.8 kg/m², 145.4 ± 43.9% and 74 ± 1% respectively. Complications included incisional hernia (n = 1), and bowel obstruction (n = 1). One patient died of acute myocardial infarction on the third postoperative day. In the ASGB group, median follow-up time was 19.7 months (range: 18-26). At 18 months postoperation BW, BMI, % IBW and % EWL values were 86.6 ± 20.6 kg 30.6 ± 6.6 kg/m2 140.6 ± 29.3% and 64 ± 1% respectively. Gastric wall erosion occurred in two patients and the bands had to be removed. These patients underwent VBG 6 months later. Complications encountered in this group were incisional hernia (n = 1), outlet stenosis and reflux esophagitis (n = 1), reservoir leakage (n = 1) and gastrointestinal bleeding (n = 1). Two patients died of pulmonary embolism and acute gastrointestinal bleeding. Conclusions: Weight reduction was not statistically significant between the two groups. ASGB was easier to perform and less invasive than VBG.     

Long-term Results on Quality of Life of Surgical Treatment of Obesity with Vertical Banded Gastroplasty

Background: Few papers assess quality of life after vertical banded gastroplasty (VBG). Methods: 100 patients with severe obesity (preoperatively mean BMI 41.7 kg m⁻²) answered an interview 60 (±2.5) months after VBG. Results: There was no fatal outcome. Nine patients had pulmonary embolus; ten patients required reoperation because of stomal stenosis. Of the 89 patients that still bore a gastroplasty at the moment of the interview, 65 had lost more than 40% of their excess weight (= ‘success’). Improvement in quality of life of these 89 patients was reflected by significant diminution of depression and back pains. Significant diminution of arterial hypertension and improvement of professional satisfaction, and of social, physical, and sexual activity was significantly related to weight loss. Conclusion: VBG resulted generally in a favorable long-term effect on quality of life. However, patients should be informed preoperatively about potential sideeffects such as possible persistent vomiting after several years, oesophagitis and gastritis, restriction in the choice of foods and prolongation of meals.     

Pouch Diverticula after Vertical Banded Gastroplasty for Morbid Obesity: Report of Three Cases

Three cases of pouch diverticula following vertical banded gastroplasty for morbid obesity are presented. Symptoms, diagnosis, treatment and etiology are discussed.     

“No Punch” Technique of Laparoscopic Vertical Banded Gastroplasty for Morbid Obesity

Background: This report describes the technical details and an initial evaluation of laparoscopic vertical gastroplasty modified for morbid obesity. After a surgical experience in 150 patients with open vertical banded gastroplasty (Mason's procedure), it was decided to perform a modified banded vertical gastroplasty. Materials and methods: Six patients were treated by this laparoscopic approach in 1997-1998. All patients were women with a mean age of 28 years (range 20-46). The mean body weight was 128 kg (range 105-146), and the mean BMI was 42.7 kg/m2 (range 35.6-53.0). Four or five 10- or 12-mm trocars were used. For all the dissection we used atraumatic ultracision (harmonic scalpel). In this procedure the technique of laparoscopic gastroplasty is performed without a circular gastric window. During the operation, 3 omental openings were made and the vertical staple-line was constructed by using a 30-mm 3-row linear stapler twice, establishing the gastric pouch. The outflow stoma was reinforced by a Gore-Tex band and calibrated to have an internal diameter of 10-15 mm. The band was sutured to itself. Results: There were no deaths or complications. Operating time was 200 min (150-240). The nasogastric tube was removed at 1-2 days. The postoperative course was characterized by normal respiratory function and minimal pain in all cases. Patients were discharged 5-6 days after operation. Conclusions: Our technique excluded the circular gastric window (i.e., “no-punch”) technique in the development of an effective and simple laparoscopic procedure to treat morbid obesity.     

Early Results of Laparoscopic Gastric Banding Compared with Open Vertical Banded Gastroplasty

Background: The introduction of laparoscopy and the increasing awareness that surgery is the only efficient long-term treatment for morbid obesity have been followed by an enormous increase in the demand for bariatric surgery. We introduced laparoscopic gastric banding (GB) in 1995, after a 15-year experience with vertical banded gastroplasty (VBG). The aim of this article is to compare the early results of this new technique with those of VBG. Methods: The charts of all the patients who underwent VBG (group A) between 1981 and 1995 were reviewed. The data for the patients who underwent laparoscopic GB (group B) between December 1995 and March 1998 were collected prospectively. Weight loss was compared between groups. All the complications arising during follow-up in the laparoscopy group were considered for analysis. In the VBG group, the complications during the first 18 postoperative months were taken into consideration. Results: There were 197 patients in group A and 76 patients in group B. The ages and risk factors were similar in both groups, but the mean body weight (116 kg vs. 121 kg, P < 0.01) and the mean body mass index (BMI) (42.7 versus 45.5, P < 0.001) were significantly higher in the laparoscopy group. If the first 30 patients of group B are excluded, duration of surgery was not different between groups. Mortality was similar, but the postoperative morbidity was higher in the VBG group (23.8% vs. 8.0%, P < 0.005). The hospital stay was much shorter in group B. Weight loss was less after 6 and 12 months in group B but was similar after 18-24 months in both groups. During early follow-up as defined in the Methods section, overall morbidity and the need for reoperation were not different between groups. Most complications were noted among the first 30 patients operated on. Conclusions: Laparoscopic GB takes no longer to perform than VBG once the learning curve is over. It is associated with less postoperative morbidity and a much shorter hospital stay. Weight loss is slower after laparoscopic GB but is similar to that achieved after 18-24 months by VBG. With proper surgical technique, laparoscopic GB can be performed adequately with a very low rate of postoperative and long-term complications. Considering the high incidence of long-term complications after VBG, it is probable that laparoscopic GB will eventually replace VBG as the restrictive procedure of choice for morbid obesity.     

Laparoscopic Adjustable Silicone Gastric Banding vs Laparoscopic Vertical Banded Gastroplasty in Morbidly Obese Patients: Long-Term Results of a Prospective Randomized Controlled Clinical Trial

Background  Aim of the study is to present long-term results of a prospective randomized single-institution clinical trial comparing laparoscopic adjustable silicone gastric banding (LASGB) with laparoscopic vertical banded gastroplasty (LVBG) in morbid obesity. Methods  A total of 100 morbidly obese patients (body mass index 40 to 50 kg/m²) were randomized to LASGB (n = 49) or LVBG (n = 51) and followed up for a minimum of 7 years. Results  Mean operative time was 65.4 min in LASGBs and 94.2 min in LVBGs (p < 0.05); mean hospital stay was 3.7 and 6.6 days, respectively (p < 0.05). Late complication rates were 36.7% in LASGBs vs 15.7% in LVBGs at 3 years (p < 0.05), 46.9% vs 43.1% at 5 years (NS), and 55.1% vs 47.1% at 7 years (NS). Late reoperation rates were 28.6% in LASGBs and 2.0% in LVBGs at 3 years (p < 0.001), 38.8% and 2.0% at 5 years (p < 0.001), and 46.9% and 7.8% at 7 years (p < 0.001). Excess weight loss in LASGBs was 41.8% at 3 years, 33.2% at 5 years, and 29.9% at 7 years; excess weight loss in LVBGs was 60.9%, 57%, and 53.1%, respectively (p < 0.05). Conclusions  This study demonstrates that in a carefully selected group of patients, LVBG is significantly more effective than LASGB in terms of late complications, late reoperations, and long-term results on weight loss.     

Vertical Banded Gastroplasty for Sleep Apnea Syndrome Associated with Morbid Obesity

We report a case of morbid obesity accompanied by obstructive sleep apnea syndrome (SAS) and obesity hypoventilation syndrome (OHS). Satisfactory weight control was obtained without significant surgical complications after vertical banded gastroplasty. With the reduction in weight, the symptoms of SAS and OHS, as well as several other complications caused by the severe obesity, disappeared. Quality of life also improved remarkably, as exhibited by improved activity performance and disappearance of irritability at waking. Thus, it appears that vertical banded gastroplasty is efficacious in the treatment of morbid obesity with sleep apnea and hypoventilation.     

Pay Status as a Predictor of Outcome in Surgical Treatment of Obesity

Background: Higher complication rates and lower success in surgery for severe obesity have been reported for patients with government pay status. We examined the effect of pay status upon outcome in surgical treatment of obesity. Methods: This was an observational study from an aggregate data set of individual patient information. Government pay status (G) was defined as full or partial medical care payment through Medicare, Medicaid, or Veterans Administration. Payment entirely by private insurance was defined as private (P). Operations were classified as either simple (S, gastric restriction) or complex (C, gastric restriction with small bowel bypass). Two measures of outcome, perioperative complication rate and weight loss success (≤50% excess weight), were examined to determine pay status effect. Results: More G than P patients were treated with simple procedures (79% vs 51%, p < 0.05). Perioperative complication rates were more common for G than P patients (14.4% vs 9.1%, p < 0.05). One-year weight loss success was higher for P than G, regardless of operation type. Conclusion: Pay status should be included in characterization of patient groups and in the analysis of results when effectiveness of surgical treatment for severe obesity is reported.     

Adjustable Gastric Loop: An Effective Method of Treatment for Morbid Obesity - Preliminary Report

During a 2-year period, the adjustable gastric loop gastroplasty was performed on more than 100 patients, all more than 100 lb (45 kg) over ideal weight. Although a small sampling in a short time-span, the initial follow-up records of weight loss have been very satisfactory. The significant advantages of this procedure over others are: (1) the procedure is fairly simple; (2) without the use of staples, this procedure does not carry the common complications of infection and follow-up surgeries for morbid obesity; (3) follow-up adjustments can be performed in the office with local anesthesia. Overall, the savings for patients, in both time and money, are another important factor in making the adjustable gastric loop a procedure of choice.     

Impact of Vertical Banded Gastroplasty on Respiratory Insufficiency of Severe Obesity

Background: Respiratory insufficiency associated with morbid obesity can include sleep apnea syndrome (SAS), obesity hypoventilation syndrome (OHS), or a combination of both. The aim of our study was to determine the safety and effectiveness of vertical banded gastroplasty (VBG) in the treatment of severely obese patients with respiratory insufficiency. Methods: From 1983 to 1994, 35 patients (25 males, ten females) who met the criteria for either SAS and OHS (19 patients) or SAS alone (16 patients) underwent VBG. Results: Six patients (17%) died of subsequent pulmonary-cardiac disease despite significant weight loss. Need for nasal continuous positive airway pressure (CPAP) decreased after VBG from 68% of patients preoperatively to 22% postoperatively. Of the ten patients with sleep studies, the apnea/hyponea index decreased from 45 ± 11 events per h preoperatively to 12 ± 6 events per h postoperatively, while per cent ideal body weight (%IBW) also decreased (pre-VBG: 268 ± 12, post-VBG: 204 ± 12). Of the seven patients with arterial blood gases, PaCO₂ decreased from 55 ± 4 torr preoperatively to 41 ± 3 torr postoperatively, and PaO₂ increased from 50 ± 4 torr preoperatively to 73 ± 6 torr postoperatively, while %IBW decreased (pre-VBG: 263 ± 16, post-VBG: 193 ± 14). Conclusion: Respiratory insufficiency is a life-threatening complication of morbid obesity. In morbidly obese patients with respiratory insufficiency, VBG offers improvement in both SAS and OHS. Respiratory insufficiency due to obesity should be considered a strong indication for VBG.     

Results of Bariatric Surgery for Morbid Obesity in Patients Older than 50 Years

Background: Surgery is increasingly used for weight loss in morbidly obese patients. The authors evaluated the safety and efficacy of bariatric surgery in patients older than 50 years. Methods: Prospective data on 62 consecutive patients (Male = 13, Female = 49) undergoing bariatric procedures between 1985-1994 were reviewed. Mean followup was 30 ± 2 months (3-48 months). All data are mean ± sem. Results: Age was 57 ± 1 year (range 50-71 years). Patients had a mean preoperative weight of 125 ± 4 kg (275 ± 9 lb) and 119 ± 6% excess body weight. A total of 68 procedures were performed: vertical banded gastroplasty (VBG = 23), Roux-en-Y gastric bypass (RYGB = 43), and biliopancreatic diversion (BPD = 2). Six patients were converted to RYGB (5) and BPD (1) after failed VBG. Hospital mortality was nil. Complications were wound infection (5), pulmonary (4), gastric leak (2), abscess (1) and others (4). Mean weight loss at 3 years was 55 ± 7 and 33 ± 6% of percent excess body weight for RYGB and VBG, respectively. Postoperative use of medications for arthritis, diabetes mellitus and asthma was reduced by 23%, 62% and 100%, respectively. Satisfaction with the outcome of treatment and weight loss was reported by 81% of patients. Six patients that were converted from jejunoileal bypass (metabolic complications) to VBG gained weight. Conclusions: Bariatric surgery is safe and well tolerated in morbidly obese patients older than 50 years. Weight loss parallels that of younger populations and is greater in patients treated with RYGB in this subgroup. Age should not be a contraindication to bariatric surgery provided the patient has obesity-related medical morbidity. Control of obesity-related co-morbid conditions is improved by weight loss.