Peptide YY secretion in morbidly obese patients before and after vertical banded gastroplasty

Background: The Peptide YY (PYY) secretion pattern was assessed in morbidly obese (MO) patients before and after vertical banded gastroplasty (VBG). Methods: 12 MO patients (10 women, 2 men) age 29-62 years, BMI 50.7 ± 9.6 kg/m², treated with a VBG were studied. Before surgery, blood samples were taken in basal conditions of fasting and 10, 15, 20, 30 and 60 min after the ingestion of a semiliquid test meal. This was repeated in the same patients 6 and 12 months after VBG. Blood samples were also taken from 6 healthy non-obese subjects as controls. PYY plasma concentration was measured by radioimmunoassay with I¹²⁵. Results: There were statistically significant differences between the preoperative PYY concentration in MO patients compared to controls. After a VBG, PYY concentration varied significantly compared to the preoperative levels.There was no significant difference between the PYY concentrations in the MO patients after VBG and the controls. Conclusion: PYY concentration is lower in MO patients compared with non-obese. After VBG, PYY concentration gradually rises to the control levels.     

Five-year results of laparoscopic vertical banded gastroplasty in the treatment of massive obesity

Background: Laparoscopic surgery appears to offer rapid recovery and low postoperative morbidity.The aim of the present study was to assess the outcome of laparoscopic vertical banded gastroplasty (LVBG) in 154 obese patients with a follow-up of 12-60 months. Patients and Methods: 154 massively obese patients (132 female) with a mean ±SEM body mass index (BMI) of 43.4±0.6 kg/m² were followed prospectively for an average of 31.7±1.4 months. LVBG was performed using 5 trocars placed in a standard fashion for laparoscopic upper gastrointestinal surgery. A 4-row stapler was used for the vertical staple-line and a stretched polytetrafluoroethylene (Gore-tex^?) band was used to reinforce the outlet. After the first 67 cases, the procedure was altered so that a 5-cm length was marked on the band. Results: Conversion to open surgery was performed in 33 cases. All patients lost weight. At 60 months follow-up, the postoperative weight was similar in the open and laparoscopic group.The subjects where 5 cm length was marked on the band had a significantly better weight loss at 36 months (30.4 ±1.2). Both early (<1 month postoperative) and late (>1 month postoperative) complications were more common in the group converted to open surgery. Postoperative stay was shorter in the laparoscopic group. Conclusions: LVBG can be performed safely and results in shorter postoperative stay than openVBG. With adherence to surgical technique (5-cm band circumference), weight-loss is maintained at an adequate level. Complications after LVBG do not exceed open VBG.     

Impartial long-term review of vertical banded gastroplasty in a low volume community hospital practice

Background: There is some concern whether bariatric surgery can be done well at low volumes or in a community hospital setting. This paper reports an impartial assessment of 25 vertical banded gastroplasties (VBG) over 13 years in a 228-bed non-teaching community hospital. Methods: Charts were reviewed and patients interviewed by an independent investigator. Complications, weight loss, satisfaction and quality of life were assessed. Results:There were no fatalities, no splenic tears, no stomal stenosis and no symptomatic gastroesophageal reflux. Two reoperations and five incisional hernias were noted. Hypertension was eliminated in 57% and dyspnea in 55%. BMI fell from 44.3 to 34.9 kg/m2 after 6.2 years. BMI decreased more than 10 kg/m2 (10-30) for 15 patients and less than 10 kg/m2 for 10 patients (4-10 for 7, 0 for 1 and a gain for 2). 56% of patients were fully satisfied with the results. Quality of life indicated excellent physical function, physical role and lack of body pain, good general health, social function, emotional role and mental health, but lower vitality.100% felt better than a year ago. Conclusion: Results from a low-volume community hospital general surgical practice are similar to those from specialized series. Obesity is so common, its non-surgical treatment so ineffective and the VBG so well established, that excluding this intervention from community hospitals is untenable.     

Hand-assisted laparoscopic vertical banded gastroplasty: technique and analysis of the first 140 cases

Background:The use of laparoscopic surgery to perform bariatric operations offers advantages to morbidly obese patients. Between January 1999 and June 2001, 140 patients underwent hand-assisted laparoscopic VBG using the Handport^™ System. Methods: In the 110 females (78.6 %) and 30 males (21.4 %), mean age was 38 years (range 19-65), mean body weight 115.8 kg (range 89-200), and mean BMI 41.8. Severe obesity was present in 41%, morbid obesity in 41% and super obesity in 9% of the patients. Comorbid conditions included hyperlipidemia in 70% of patients, arthritis in 44%, hypertension in 38%, COPD in 18%, GERD in 12%, impaired glucose tolerance and diabetes in 10%, sleep-apnea in 5% and coronary heart disease in 1%. Results: There was no operative mortality. Mean excess weight loss was 60.7% at 12 months and 63% at 18 months. Mean BMI was 30.8 at 12 months and 30.4 at 18 months. A decrease in BMI of 11 kg/m² was reached at 12 months. According to the Reinhold Classification (residual excess weight <50%), good to excellent results were achieved in 75.7% at 1 year and in 77.7% at 18 months. Early postoperative complications were 4 wound infections, 3 atelectasis or pneumonia, 1 deep vein thrombosis, 1 subphrenic abscess and 1 wound hematoma. Late postoperative complications were 2 incisional hernias, 2 esophagitis, 1 symptomatic gallstones, 1 staple-line fistula, 9 protracted vomiting and 6 band-related problems. Conclusions: The short-term results compare favorably with the literature on open VBG. Because of the reduction of perioperative risks with the laparoscopic approach, bariatric surgery should be performed laparoscopically if the expertise is available.     

Gastrointestinal quality of life following laparoscopic vertical banded gastroplasty

Background: Laparoscopic vertical banded gastroplasty (LVBG) is a safe and effective treatment for morbid obesity. Previous studies disclosed a significant improvement in the health-related quality of life after substantial weight loss following VBG. Data regarding the specific gastrointestinal quality of life following LVBG is lacking. Materials and Methods: 223 patients who underwent LVBG for morbid obesity were studied prospectively. Quality of life was measured by the Gastrointestinal Quality of life Index (GIQLI), a 36- item questionnaire before surgery, and at 6 months, 1 year and 2 years after surgery.The questionnaire is divided into 5 domains, and the maximum score is 144. Results: After LVBG, weight loss has been good. Mean BMI decreased from 43.2 to 31.3 after 2 years. Co-morbidities were eliminated in 71%. 84.3% of patients were satisfied with the results. However, the score of GIQLI remained similar before and after surgery. Preoperative score was 106.2±19 points. The score became 116.6±9, 106.8±21, and 108.5±20 at 6 months, 1 year and 2 years after surgery respectively.The patients had improvement in 3 domains of the questionnaire (social function, physical status and psychological emotions) but decreased in domains of core symptoms and disease-specific items. Conclusion: Although LVBG was effective in reduction of weight and resolution of co-morbidities in morbidly obese patients, the specific gastrointestinal quality of life did not improve. Many patients developed some specific gastrointestinal symptoms in order to obtain weight reduction.     

Laparoscopic Roux-en-Y gastric bypass for severe gastroesophageal reflux after vertical banded gastroplasty

Background: Vertical banded gastroplasty (VBG) is sometimes associated with complications such as pouch obstruction, dilatation, and gastroesophageal reflux. This occasionally requires surgical revision, in many cases to a Roux-en-Y gastric bypass (RYGBP). Case Report: A 47-year-old woman with severe obesity developed severe symptoms of stenosis of the pouch outlet and gastroesophageal reflux 15 years after VBG. Laparoscopic conversion to a RYGBP was performed. At 9-month follow-up, she lost an additional 32 kg and had complete resolution of her reflux. Conclusion: In this patient, laparoscopic re-operative RYGBP produced additional weight loss, and improved gastroesophageal reflux that occurred many years after having a VBG. Laparoscopic conversion of a VBG to RYGBP is feasible, and may confer the benefits of other minimally invasive abdominal procedures to this high-risk patient group.     

Vertical banded gastroplasty in the Aegean Region of Turkey

Background: Obesity is increasing in Turkey. The first experience with vertical banded gastroplasty (VBG) with regular intermediate-term follow-up in the Aegean Region of Turkey is presented. Methods: From November 1993 to August 1999, 40 morbidly obese patients underwent VBG. The patients were evaluated on the basis of excess weight loss (EWL) and satisfaction with the operation. Results: Regular follow-up was obtained in 38 patients (95%), with mean follow-up 27.2 months (14-85). Average preoperative body weight (BW) was 141.4 kg (93-238) and body mass index (BMI) was 52.3 kg/m² (41-77.8). Average EWL was 64.1% (21.2-92.3). Average postoperative BW and BMI were 93.3 kg (70-145) and 34.4 kg/m² (25.1-53) respectively. 35 of 38 patients (92%) lost more than 25% of EW and 28 of 38 (73.6%) lost more than 50% of EW. After weight loss, hypertension disappeared or improved in 86% of patients and diabetes resolved in 75%. Sleep apnea disappeared in 100% of patients. The early and late complication rates were 7.9% and 15.8% respectively. 33 of 38 patients (87%) were satisfied with the operation. Conclusion: VBG was safe and effective, resulted in acceptable weight loss, and the vast majority of patients were satisfied.     

Effect of vertical banded gastroplasty on hypertension,diabetes and dyslipidemia

Background: Operations for morbid obesity that are effective in inducing weight loss improve blood pressure, glycemic control and dyslipidemia. Our purpose was to study the effectiveness of VBG in improving hypertension, diabetes and dyslipidemias in morbidly obese patients. Methods: Retrospective analysis of a cohort of 80 morbidly obese patients was conducted. Characteristics of patients were: mean age 37 years; gender: women 65, men 15; mean initial BMI 49.5 kg/m²; follow-up >5 years in 52 patients. Blood pressure, cholesterol and triglyceride levels and glycemia were assessed preoperatively and 1, 3, 6, 12, 18 months and every year after VBG. Results: Hypertension resolved in 65.5% of patients (38 of 58), serum cholesterol level became normal in 34.28% of patients (12 of 35), triglyceride level became normal in 77.77% (7 of 9) and diabetes resolved in 55.55% (5 of 9). Conclusion: Weight loss induced byVBG improves blood pressure, triglyceride levels and glycemia.The beneficial changes occur early in the postoperative period and last 5 years or more, despite of the trend to regain some weight. Improvements in risk factors were greater in patients with higher preoperative values.     

Improvement of weight loss and metabolic effects of vertical banded gastroplasty by an added duodenal switch procedure

Background: Some patients who underwent vertical banded gastroplasty (VBG) need revisional operations because of poor weight loss and remaining comorbidities. The duodenal switch (DS) procedure with partial gastrectomy is known as an effective method for treatment of severe obesity and related dyslipoproteinemias and diabetes mellitus type 2 (DM2). Other investigations have shown that DS without gastric resection similarly corrects hypercholesterolemia and DM2 in the "less than" morbidly obese patients. Methods: Based on this knowledge, we performed a DS simultaneously with hernioplasty and panniculectomy in a 63-year-old woman with a fair EWL (36.4%), with remaining hypercholesterolemia and DM2 4 years after VBG. The pouch stoma diameter was 13 mm, and there was no pouch dilation nor staple-line disruption.The previously partitioned stomach was left in place. H2-blockers and polyvitamins were prescribed after operation. Results: 1 year after DS there were no postoperative complications and undesirable effects except slight anemia. DS allowed improvement in weight loss, improved carbohydrate handling without need for insulin or other hypoglycemic agents, and corrected severe hypercholesterolemia. Conclusion: DS per se in the case presented had a decisive effect on DM2 and hypercholesterolemia. DS should be kept in mind as a second-step malabsorptive procedure after a failed purely restrictive operation.     

Technical Modification of Laparoscopic Vertical Banded Gastroplasty

Background: Technical improvements of laparoscopic bariatric procedures are important to minimize operative time and increase safety and simplicity. Methods: A modification is described of the "classic" Mason - MacLean vertical banded gastroplasty (VBG), performed by laparoscopy, with wedge resection of the gastric fundus, thus avoiding the time-consuming and technically difficult gastro-gastrostomy window. Results: The technique used was simple and safe, and required less operative time than the "classic" method, without serious intra- or postoperative complications. Weight loss in 18 patients who underwent the modified laparoscopic VBG and were followed-up for 1 year was equal to that achieved in patients who underwent openVBG at our Institution. Gastro-gastric fistula was not observed in upper GI barium studies performed 12 months postoperatively. Conclusion: The modified technique is preferable when lap-VBG is indicated for surgical treatment of morbidly obese patients.     

Low-Back Pain in Morbidly Obese Patients and the Effect of Weight Loss Following Surgery

Background: Although low-back pain (LBP) is a common health problem and a source of significant discomfort, disability and work absences, its incidence, severity and outcome have not been extensively investigated in morbidly obese patients undergoing bariatric surgery. Methods: 50 morbidly obese candidates for vertical banded gastroplasty (VBG) were asked to fill in a questionnaire, to assess the incidence and severity of any existing LBP symptoms. 50 non-obese patients, admitted to our surgical unit for management of several benign conditions, were also asked to fill in the same questionnaire and served as controls. 24 months after VBG, the morbidly obese patients were again evaluated for their LBP symptoms. Results: LBP was identified in 29 morbidly obese patients (58%) preoperatively and in only 12 (24%) of the lean controls (P<0.01). 2 years after VBG, with a significant excess weight loss (P<0.0001), only 10 patients continued to have LBP but less frequently and requiring reduced doses of medications compared with the preoperative condition. In the remaining 19 patients with preoperative positive LBP history, the postoperative weight loss was associated with complete resolution of the symptoms. Conclusion: The frequency of LBP is significantly higher in morbidly obese patients than in lean subjects. Surgical weight reduction results in significant improvement and even disappearance of this obesity co-morbidity.     

The Effect of Surgical Weight Reduction on Functional Status in Morbidly Obese Patients with Low Back Pain

Background: Although low back (LBP) pain is not a lifethreatening disease, it is a source of significant discomfort and disability and accounts for work absences. It has been shown previously that morbid obesity is associated with increased frequency of LBP and that surgical weight loss improves the symptomatology. However, there are no studies to quantitatively assess the exact degree of functional disability caused by severe obesity and the degree of improvement of LBP that follows weight loss from bariatric surgery. Methods: 29 morbidly obese candidates for bariatric surgery with LBP, weight 132.5±27 (mean±SD) kg and BMI 47.2±8.8 kg/m² were examined for their functional status using psychometric instruments specifically designed to objectively assess the patients' complaints. The preoperative scores were measured by a) visual analogue scales (VAS1, VAS2, VAS3), b) Roland-Morris disability questionnaire, c) Oswestry LBP disability questionnaire, and d) Waddell disability index, and were compared with the scores obtained by the same instruments 2 years after vertical banded gastroplasty. Results: The postoperative weight (92.3±19 kg) and BMI (32.9±6.3 kg/m²) of the 29 patients were significantly reduced (P<0.001). The improved functional disability scores were statistically significant: a) VAS1 1.59±1.86 (mean±SD) vs 0.32±0.64, P<0.001; b) VAS2 5.5±1.97 vs 2.14±1.88, P<0.001; c) VAS3 0.77±1.11 vs 0.09±0.29, P=0.006, d) Roland-Morris 7.89±5.11 vs 1.89±2.13, P<0.001; e) Oswestry 21.22±15.63 vs 5.61±7.51, P<0.001; f) Waddell 2.81±1.37 vs 0.56±0.72, P<0.001. Conclusions: Surgical weight loss significantly improves the degree of functional disability of morbidly obese patients suffering from LBP.     

Adenocarcinoma of the pouch after silastic ring vertical gastroplasty

A 52-year-old woman was admitted because of epigastralgia, anorexia and recently increased vomiting, 2 years after silastic ring vertical gastroplasty. On gastroscopy, a tumor mass was visualized in the pouch near the "neo-pylorus". Biopsies confirmed adenocarcinoma. She underwent total gastrectomy, and has no evidence of recurrence at 1 year.The literature on gastric carcinoma after gastroplasty is reviewed.     

Carcinoma in the Gastric Pouch Years after Vertical Banded Gastroplasty

A 67-year-old lady presented with anemia and weight loss 15 years after vertical banded gastroplasty. The cancer was confined to the pouch, which is suggestive of a relationship to the anti-obesity surgery. A brief review with possible contributing factors is presented.     

Laparoscopic Vertical Banded Gastroplasty: Early Experience

Background: The tremendous development of laparoscopic surgery in the last decade is being applied to bariatric surgery. Laparoscopic vertical banded gastroplasty (LVBG) is technically feasible by laparoscopy. Methods: From August 1998 to August 1999, 13 patients underwent LVBG. The technical difficulties are discussed. Results: Operating time ranged from 105 to 420 minutes. 11 patients have lost 45-55% of their original weight. Inserting an esophageal bougie no. 11 from the beginning of the operation and using the laparoscopic set-up described, made the procedure shorter, safer and easier for patients and surgeon. Conclusion: LVBG is technically feasible for the laparoscopic bariatric surgeon who is experienced in the handling and control of laparoscopic instruments and hand-eye coordination. The early results are satisfactory. Preoperative counseling is an integral step for the operation.     

Gastric Cancer Occurring After Vertical Banded Gastroplasty

A case of gastric cancer after vertical banded gastroplasty (VBG) is presented. A 44-year-old man presented with vomiting and weight loss 6 years after VBG. Endoscopy revealed a poorly differentiated gastric adenocarcinoma. The patient underwent a Whipple pancreaticoduodenectomy and received chemotherapy. He expired 6 months later. From our case and review of the literature, development of gastric cancer after VBG is very rare. The authors suggest that patients undergoing VBG be monitored by endoscopy after the operation.     

Eating behavior in morbidly obese patients undergoing gastric surgery: differences between obese people with and without psychiatric disorders

Background: This study analyzes eating behavior in a group of morbidly obese patients who have undergone gastric reduction surgery for weight loss, and evaluates whether the existence of psychiatric comorbidity marks significant differences in their eating behavior. Methods: The study group was composed of 100 morbidly obese patients (85 females, 15 males) who had received surgical treatment for weight reduction (vertical banded gastroplasty). 40 of these patients (40%) met ICD-10 criteria for the diagnosis of psychiatric disorders and were included in the "Psychiatric Obese group" (PO). The other 60 patients (60%) did not show ICD-10 diagnostic criteria and were included in the "Non-Psychiatric Obese group" (NO). Each patient completed the Binge Eating Scale (BES), the Three Factor Eating Questionnaire, the Bulimia Investigatory Test Edinburgh (BITE), and the Eating Disorder Inventory (EDI). Results: Significant differences were found between the two groups (PO and NO) in the Binge Eating Scale (p<0.001), Three Factor Eating Questionnaire subscale Disinhibition (p<0.001), BITE (p<0.001), Eating Disorder Inventory subscale Perfectionism (p<0.002), and Global EDI (p<0.001). Logistic regression analysis showed correlation between PO group and Global EDI (Odds Ratio OR=1.43) and BITE (OR=1.16). No significant gender differences were found for eating behavior, clinical diagnosis, age, percentage of weight loss, time after operation, and BMI before surgery. Conclusion: Surgically treated morbidly obese patients with a psychiatric disorder (PO) have a more destructured eating pattern (with a predominance of binge eating and disinhibition) than NO.     

Laparoscopic Vertical Banded Gastroplasty - an Effective Long-Term Therapy for Morbidly Obese Patients?

Background:Vertical banded gastroplasty (VBG) has previously been documented as an effective treatment for morbid obesity.We have described a laparoscopic technique to perform this operation. Followup data are now presented. Methods: A consecutive series of 139 morbidly obese patients were operated on with laparoscopic VBG. The patients were assessed with respect to peri- and postoperative morbidity, postoperative recovery and weight reduction up to 5 years thereafter. Results: Conversions to an open operation (n=6) and early reoperations (n=3) occurred in the early part of the series. Late complications were observed in 8 patients. The average weight reduction after 1 year was 50% of excess body weight, which remained also after 2 years.The continued follow-up covering 3 to 5 years postoperatively revealed a moderate weight gain in about 20% of patients. Conclusion: VBG can be safely performed by use of the laparoscopic technique. The average weight reduction after 1 and 2 years was 50% of excess body weight, whereafter tendency to partial weight gain was noted, suggesting an outcome comparable to that documented after the open surgical approach.     

Determinants of Long-Term Satisfaction after Vertical Banded Gastroplasty

Background: The long-term usefulness of vertical banded gastroplasty (VBG) in achieving weight loss is controversial, and adverse effects related to the procedure may attenuate patient satisfaction. Our objective was to evaluate patient satisfaction, and to identify parameters that are related to such satisfaction, 3 to10 years after VBG. Methods: All consecutive patients who underwent VBG in one surgical ward were invited for a follow-up study 3 to 10 years after surgery. Questions relating to symptoms and quality of life were evaluated in a personal interview using a structured questionnaire. Results: Of the 122 patients who underwent VBG from 1986 to 1992, 75 patients were located and agreed to participate in the follow-up study. The average time since surgery was 5.4 ± 1.8 years. The average weight loss was 24.9 ± 12.4%, representing an excess body-weight loss of 58.6 ± 30.4%. Overall, 65% of the patients were satisfied with the results of surgery while 19% expressed dissatisfaction. Significant improvement was seen in respiratory difficulties, ability to perform physical exercise, and mental status. Successful weight loss and the frequency of respiratory difficulties were the only independent parameters associated with patient satisfaction. Although vomiting, gastroesophageal reflux and difficulty in swallowing occurred in over two-thirds of the patients, their presence was not correlated with patient dissatisfaction. Conclusion: Despite the presence of a multitude of adverse effects, the majority of our patients were satisfied with the long-term results of VBG. Successful weight loss and improvement in respiratory difficulties were the major determinants of patient satisfaction.     

Laparoscopic Vertical Banded Gastroplasty: Early Results with the JOVO Procedure

Background: Vertical banded gastroplasty (VBG) is an established treatment for morbid obesity for selected patients. This study seeks to assess the effectiveness of a laparoscopic version, the JOVO procedure, of the VBG. Methods: An independent surgeon interviewed all patients, who had had the JOVO procedure at one institution, evaluating weight loss, comorbid conditions, satisfaction and quality of life using the 36-item short-form health survey (SF-36). Results: 14 JOVO procedures were done by two surgeons. Mean body mass index was 44 kg/m², mean age 30 years and each patient had at least one comorbid condition. Mean operative time was 165 minutes. There was 1 complication, a suspected gastric leak requiring reoperation. Excluding this patient, mean hospital stay was less than 48 hours. Mean weight loss 4 weeks after surgery was 9 kg or 18% of excess weight. Mean excess weight loss of the 5 patients available for 1-year follow-up was 42% at 6 and 85% at 12 months; 1 did not continue to lose weight. All but 1 preoperative comorbid condition resolved or improved. 13 of the 14 patients were fully satisfied. SF-36 scores were high in the 13 that lost weight, especially in physical and social functioning areas. Conclusion: The JOVO procedure is safe and reproduces laparoscopically the early weight loss of open VBG with much shorter hospital stay and low complication and failure rates. Longer follow-up and larger numbers are needed.