Long-term Follow-up on the Effect of Silastic Ring Vertical Gastroplasty on Weight and Co-Morbidities

Background Silastic ring vertical gastroplasty (SRVG) is a simple, effective and reproducible restrictive operation for the treatment of morbid obesity. Over the last years, it has lost its popularity due to the development of adjustable gastric banding systems performed laparoscopically. In order to evaluate the long-term effect of SRVG on weight loss and co-morbidities, we reviewed the results of SRVG operations in our institution. Methods We reviewed SRVG operations performed in our University-affiliated General Hospital. Data was collected from the patients’ in-patient records, their outpatient-clinic files, and from a telephone interview. Results Between 1989 and 2001, 162 patients were operated upon. Complete follow-up was obtained of 115 patients (71%). The mean follow-up was 7.1 ± 3 years (range 4 to 16 years). Mean preoperative BMI was 47 kg/m2 (range 34 to 69 kg/m²). Maximal weight loss was obtained within 1 year to a mean BMI of 29 kg/m², with a mean excess BMI loss of 67%. Subsequently, there was a small increase in BMI, which stabilized at 34 kg/m² up to 15 years after the operation. A rapid, significant improvement in obesity-related co-morbidities was observed regarding hypertension (81%), diabetes (100%), sleep disorders (90%), osteoarthritis (83%) and ischemic heart disease (75%). There was no peri-operative mortality. Early complication rate was 10%. Late complications included postoperative ventral hernia (18%), esophagitis (31%), ring stricture (19%), ring erosion (2 patients), failure of staple line (8%) and obstruction of the pouch with food (19%). 35 patients (30%) required another procedure, 8 of them were eventually converted to other bariatric operations, and 2 patients had the ring removed and refused another bariatric procedure. The overall satisfaction rate was 86%. Conclusions SRVG is a simple, safe and effective bariatric operation in selected patients with morbid obesity. It results in a rapid, excellent effect on obesity-related co-morbidities and good long-term effect in weight loss, which compares positively with other, more complicated bariatric operations.     

Weight loss and eating behavior following vertical banded gastroplasty

Background Bariatric surgery is the treatment of choice for patients with morbid obesity. In addition to surgery, postoperative dietary behavior is an important mediator of weight loss and, therefore, critical in influencing outcome. Surgical treatment of obesity is not an alternative to dieting but a method to enforce dieting. Methods We evaluated early weight loss and postoperative eating behavior over time. Preoperatively as well as 6 months, 1 and 2 years after vertical banded gastroplasty (VBG), 91 patients were psychologically assessed using a semi-structured interview and a psychological questionnaire focusing on eating behavior. Results Over time, we found significant changes in weight, mostly in the 1st postoperative year (EWL= 52.0%); at 2 years, EWL was 61.5%. Patients reported substantial changes in feelings of hunger, appetite, satiety, and eating behavior; however, most improvements waned over time. In addition, there was a wide variability in changes within our patient group, and changes in weight loss appeared to be related to changes in restrained eating. Conclusion VBG not only leads to considerable weight loss, but also to significant improvements in eating behavior, at least within 2 years. However, most improvements wane over time and not all patients profit in the same way.     

Gastric Pouch Adenocarcinoma and Tubular Adenoma of the Pylorus: A Field Effect of Dysplasia following Bariatric Surgery

There are reports of gastric carcinoma following bariatric surgery, but it is unclear if these procedures predispose to malignancy.We present a case of a 60-year-old man who, 15 years after vertical banded gastroplasty (VBG), had a massive upper GI bleed. Endoscopy revealed a large tumor of the gastric pouch. Histology confirmed an intestinal type of gastric adenocarcinoma arising in a background of H. pylori-negative gastritis with atrophy, foveolar hyperplasia and intestinal metaplasia. An incidental tubular adenoma at the pylorus was also identified. The pathogenesis of gastric pouch carcinoma is discussed. The present example of neoplastic change in both the pouch and pylorus may indicate that a field effect for dysplasia develops subsequent to VBG.     

Outcome Following Bariatric Surgery in Super versus Morbidly Obese Patients: Does Weight Matter?

Background: Numerous investigators have attempted to identify prognostic indicators for successful outcome following bariatric surgery. The purpose of this study was to determine whether degree of obesity affects outcome in super obese [>225% ideal body weight (IBW)] versus morbidly obese patients (160-225% IBW) undergoing gastric restrictive/bypass procedures. Methods: Since 1984, 157 patients underwent either gastric bypass or vertical banded gastroplasty. Super obese (78) and morbidly obese (79) patients were followed prospectively, documenting outcome and complications. Results: Super obese patients reached maximum weight loss 3 years following bariatric surgery, exhibiting a decrease in body mass index (BMI) from 61 to 39 kg/m² and an average loss of 42% excess body weight (EBW). Morbidly obese patients had a decrease in BMI from 44 to 31 kg/m² and carried 39% EBW at 1 year. After their respective nadirs, each group began to regain the lost weight with the super obese exhibiting a current BMI of 45 kg/m² (61% EBW) versus 34 kg/m² (52% EBW) in the morbidly obese at 72 months cumulative follow-up. Currently, loss of 50% or more of EBW occurred in 53% of super obese patients versus 72% of morbidly obese (P < 0.01). Twenty-six percent of super obese patients returned to within 50% of ideal body weight (IBW) while 71% of morbidly obese were able to reach this goal (P < 0.01). Co-morbidities and complications related to surgery were similar in each group. Conclusions: Super obese patients have a greater absolute weight loss after bariatric surgery than do morbidly obese patients. Using commonly utilized measures of success based on weight, morbidly obese patients tend to have better outcomes following bariatric surgery.     

Experience with Laparoscopic Adjustable Gastric Banding (La-Band System) up to 8 Years

Morbid obesity occurs in 2-5% of the population in Western countries.

Laparoscopic adjustable silicone gastric banding is a minimally invasive, adjustable and reversible procedure for the treatment of morbid obesity.

The lap-band system was evaluated retrospectively in a series of 222 patients. Postoperative outcome and weight loss patterns at up to 8 years follow-up are presented. The most frequent late complications were a leak between the port and the catheter, which occurred in 21 patients (9,4%) and total and irreversible food intolerance due to pouch dilation and/or slippage, which occurred in 13 patients (5,8%). The postoperative BMI reductions are successful and stable after a follow-up of up to 96 months. The lap-band system seems an effective procedure for achieving appreciable and stable weight loss up to 8 years of follow-up and the complications and re-operation rates are acceptable. In 81% of the cases also, the patient is very satisfied with the results of the operation. From the 47,3% who found their quality of life before the operation bad or even devastating, 93% envoy life after the operation like never before.     

Roux-en-Y Gastric Bypass after Failed Vertical Banded Gastroplasty

BACKGROUND: Vertical banded gastroplasty (VBG) was the restrictive procedure of choice for many years. However, VBG has been associated with a high rate of long-term failure. We reviewed our experience of conversion of failed VBG to Roux-en-Y gastric bypass (RYGBP). METHODS: The data on all patients undergoing conversion of failed VBG to RYGBP were reviewed. Failed VBG was defined as insufficient weight loss (BMI > 35 kg/m2) and/or VBG-related complications. RESULTS: We performed 24 conversions from VBG to RYGBP. Median age was 40 +/- 8 years (range 28 to 61). Preoperative weight was 111 +/- 25 kg (range 85 to 181), and median BMI was 41 +/- 8 kg/m2 (range 30 to 69 kg/m2). Indication for conversion was: VBG failure in 18 patients and VBG complications in 6 patients. A gastrectomy (total or proximal) had to be performed in 5 cases (21%). The conversion was performed by laparoscopy in 13 cases. Postoperative complications occurred in 4 patients (16.7%). There were no leaks, nor mortality. Postoperative BMI was 31 kg/m2 (range 25 to 42) at a median follow-up of 12 months (range 3 to 36 months). The average percentage of excess weight loss was 62% at 1 year. CONCLUSION: VBG has been associated with a significant reoperation rate for failure and/or complications. Conversion to RYGBP is effective in terms of weight loss and treatment of complications after VBG. Gastrectomy and resection of the staple-line could reduce such complications as leaks and mucocele. Although technically challenging, conversion of VBG to RYGBP is feasible, with acceptable morbidity and no mortality. The conversion is feasible laparoscopically.     

Laparoscopic Roux-en-Y Gastric Bypass as a Revision Procedure after Restrictive Bariatric Surgery

Background  Adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG) have been extensively used to treat morbid obesity. Patients with insufficient weight loss or complications may require surgical revision. The laparoscopic Roux-en-Y gastric bypass (LRYGBP) is one of the most common procedures currently used for revision. The aim of the study was to analyze surgical outcomes of 30 consecutive patients who underwent revision to LRYGBP in a 2-year period. Methods  The prospectively constructed database and the medical records of all patients undergoing revision to LRYGBP were reviewed. Demographics, surgical details, results, and complications were analyzed. Results  There were 23 women and seven men with a mean age of 41.1 ± 9.7 years (r = 25–61). Mean body mass index (BMI) was 40.0 ± 7.5 kg/m² (r = 27.2–65.2). Initial operation was AGB in 24, VBG in five, and both in one patient. In ten patients, the band had been removed before revision, in 13 cases, band removal and LRYGBP were performed in one surgical intervention, and in two patients, it was performed in a two-step surgery. There were two conversions to open surgery. Five patients presented major surgical complications. Hospital stay averaged 5.1 days (r = 3–25). Mean percent excess body weight loss at 6 and 12 months was 61.7 ± 27.5 and 81.2 ± 20.5 kg/m², respectively. Mean percent low body mass index at 6 and 12 months was 22.5 ± 9.1 and 29.1 ± 11.4 kg/m², respectively. Conclusions  LRYGBP as a revision procedure is feasible in most patients. Surgical complications are more frequent.     

A Nationwide Survey on Bariatric Surgery in France: Two Years Prospective Follow-up

Background Most studies on bariatric surgery outcomes have been performed in clinical trials (eg. the SOS) or reflect the clinical experience and practice of specific and experienced centers. Little is known about the current practice at a nationwide level. Methods This is a systematic nationwide study on the 2-year outcome of all consecutive 1,236 bariatric operations performed in France. Data on mortality, weight loss, complications, and patient satisfaction were collected independently from the medical and surgical team involved in the patients’ care. Results 87.3% of the patients underwent an adjustable gastric banding (ABG), 8.6% a vertical banded gastroplasty (VBG), 3.8% a Roux-en-Y gastric bypass (RYGBP) and 0.3% a biliopancreatic diversion (BPD). Loss of follow-up was 12% at year 1 and 18% at year 2. The rate of laparoscopic procedures was 98% for ABG and 73% for RYGBP. Mortality rate was 0.16% in the operative period and 0.27% during follow-up. Excess weight loss ranged from 43% (AGB) to 66% (RYGBP). Co-morbidities improved in more than 70% of patients. Conclusion Outcomes of bariatric surgery in routine practice (mortality, weight loss, course of co-morbidities, and quality of life) are similar to the results published in clinical trials.     

Weight Loss and Complications After Vertical Banded Gastroplasty

We have performed 124 vertical banded gastroplasties (VBG) according to Mason, except that we used a collar 5.5 cm in circumference. We carried out a midline incision in 68 cases and a left subcostal incision in 56, with double application of a 2-row stapler with reinforcement in the first 69 cases and a single application of a 4-row stapler in 55 (15 with reinforcement, 40 without). We have followed 107 (86.2%) patients for a mean of 30 months (range 3-84). The mortality rate was nil. The intraoperative complications were three spleen lacerations (splenectomy), and the early complications were two gastric leaks (re-intervention) and one gastric bleeding. The late complications were one gastric perforation (re-intervention), four outlet stenoses (one re-intervention), one bleeding by collar erosion and nine ventral hernias (occurring only with the midline incision). The percentage excess weight loss was 46.3 ± 16.4 at 6 months, 53.4 ± 17.9 at 1 year, 47.8 ± 19.6 at 3 years, and 45 ± 23.3 at 5 years. In 12 cases the weight loss was unsatisfactory (less than 30% of the initial excess weight). Often such failures were due to staple-line disruption. We have had no staple-line disruptions since we stopped performing the reinforcement. VBG has a low incidence of complications, but sometimes these may be serious. In our opinion, the technical procedures which offer a stronger vertical partition give better results for weight loss.     

Staple-line Disruptions in Vertical Banded Gastroplasty Related to Different Stapling Techniques

We performed one or more upper G. I. barium single-contrast studies on 125 out of 166 Mason vertical banded gastroplasty (VBG) operated patients (total: 226 X-ray examinations during a 3 month-10 year postoperative period). Forty four patients had a staple-line performed by double application of a 2-row stapler with manual reinforcement (group 1); 12 had a single application of a 4-row stapler with reinforcement (group 2); the last 69 patients had a partition with a 4-row stapler without reinforcement (group 3). A staple-line disruption was observed in 34 cases (27.2%); 17/44 (38.6%) cases belong to group 1, 6/12 cases (50%) to group 2 and 11/69 cases (15.9%) to group 3. The range of breakdowns diameter was 2-30 mm (nine cases double, one case quadruple). In 16 out of 34 cases we observed a preferential contrast pathway through the perforations. In 23 cases we noted a weight regain and in one case an initial failure on weight loss; in 12 cases the excess weight loss (EWL) was less than 30%. In group 3, we found two tiny perforations at the top of the partition, but another nine along with the staple-lines. In our experience, staple line disruptions are only reduced using the 4-row stapler without reinforcement; even with this stapling technique late breakdowns along the staple-line, not only at the apex of the partition, can occur.     

Gastric Banding for Treatment of Morbid Obesity: Preliminary Results

Background: gastric banding (GB) has been used for treatment of morbid obesity. Methods: a banding device, introduced by Broadbent and consisting of a self-blocking nylon strip covered with a silicone tube, was used in 13 patients who have completed 1-year follow-up. This device was used for its mechanical properties, biocompatibility, ease of insertion and low cost. Results: at 1 year, mean excess weight loss was 51.6%, with all but one patient losing more than 25% of excess weight. Associated illnesses resolved. There were two complications (15%): one patient required band removal for self-induced vomiting and one patient required repair of an incisional hernia. Conclusions: GB has had good results thus far. Reported differences depend on materials, stoma diameter, pouch size, and developing techniques.     

Feasibility of Sleeve Gastrectomy as a Revision Operation for Failed Silastic Ring Vertical Gastroplasty

Background  Restrictive bariatric operations are efficient with low morbidity but entail high rate of failure on follow up of several years. We present our experience in laparoscopic revision of patients who previously underwent silastic ring vertical gastroplasty (SRVG) into laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB). Methods  Data on 12 patients who underwent revisional operations after SRVG was prospectively collected. Six patients underwent LRYGB and six patients underwent LSG. The pathogeneses for failures of SRVG were disruption of staple line, enlargement of gastric pouch, and opening of the ring. Results  The average age and body mass index (BMI) were 39 and 43, respectively, in the LSG group versus average age and BMI of 39 and 45, respectively, in the LRYGP group (p = 0.45 and p = 0.35, respectively). The average operative time were 206 and 368 min in the LSG and LRYGB groups, respectively (p < 0.01). There were five postoperative complications among LSG group versus two complications in LRYGB group (p < 0.01). Patients who underwent LSG suffered from the following complications: staple line leak in two patients, intra-abdominal hematoma in one patient, intra-abdominal collection in one patient, and gastric outlet obstruction in one patient. Anastomotic leak and wound infection were the complications seen among patients underwent LRYGB. All complications were treated conservatively without necessitating immediate reoperations. Follow-up has shown adequate reduction of body weight and improved quality of life in both groups of patients. Conclusions  Revisional bariatric operation is a challenging laparoscopic procedure with higher morbidity compared to primary bariatric operations. Morbidity of LSG compared to LRYGB as a revisional procedure for SRVG is significantly higher.     

Gastro-Clip® Gastroplasty: A Very Long-term Complication

For most surgeons, the gastro-clip gastroplasty is an unfamiliar operation. It was performed during the mid 1980s as an alternative to more complex bariatric operations. However, the device had problems. Because of its rigid nature, it occasionally eroded into the stomach and chest. Many of these devices required removal. However, patients may occasionally present with delayed complications. We present a patient with a Gastro-clip gastroplasty, who presented years after the procedure with a functional gastric outlet obstruction.     

Why the Operation I Prefer is Vertical Banded Gastroplasty 5.0

Vertical banded gastroplasty (VBG) is easy for the patient, requiring no nasal gastric tube, gastrostomy, feeding enterostomy, or central venous line. Clear liquids are begun the first morning and puréed foods the second day. VBG with a 5.0 cm collar and a 13 ml pouch provides sufficient weight control with minimal risk and side effects. Splenectomy risk is 0.3%, peritonitis from leak 0.6% and operative mortality 0.24%, VBG causes no malabsorption or bacterial overgrowth because there are no blind segments. VBG does not predispose to difficult to diagnose, lethal, closed segment obstruction because of the absence of exclusion. VBG minimizes risk of acid peptic disease by preserving normal feedback control of acid secretion. Revisions have been less than 2% per year. The first 250 patients to be followed for 5 years with VBG-5.0 showed an 80% success in achieving 25% of excess weight loss without revision. For these successful patients the average percentage excess weight loss was 60% for the morbid obese (MO 160 to 225% of ideal) and 52% for the super obese (SO over 225% of ideal). Absolute weight averages changed from 122 to 86 kg for MO and from 159 to 110 kg for SO.     

Complications of Biliopancreatic Diversion Surgery as Proposed by Scopinaro in the Treatment of Morbid Obesity

Background. This study concerns 33 patients treated for morbid obesity with the procedure proposed by Scopinaro. Results are reviewed retrospectively in terms of complication rates. Methods. The group consisted of ten men and 23 women with a mean age of 34 years (range 20-51 years), and a mean BMI of 49.5 kg m⁻² (range 37-77). Adequate attempts at medical management had failed repeatedly. The operative procedure involved a 2/3 partial gastrectomy and biliopancreatic diversion by Roux-en-Y reconstruction 50 cm before the ileocecal valve. In one patient, a cholecystectomy was added. Results. The mean weight loss after 6 months was 18.9% of the initial weight, with mean BMI 41 kg m⁻² (range 29-60). Early complications included four wound infections (15%), while two patients complained of an early dumping syndrome (6%), treated by dietary measures. There were no respiratory infections and no pulmonary embolism, likely as a result of the thoracic epidural anesthesia and high doses of prophylactic heparin used. There was no mortality. As to late complications, nine patients complained of diarrhoea due to bacterial overgrowth (27%) and were treated with antibiotic therapy. There were five incisional hernias (15%). Five patients had a peptic ulcer (15%) and required medical treatment. Two patients had acute cholecystitis (6%). One patient had an afferent loop obstruction (3%), requiring reoperation. Conclusions. Overall, this series of intestinal diversion procedures by the method of Scopinaro had a larger complication rate than generally reported.     

Pharmaceutical Savings after Gastric Bypass Surgery

Background: Clinically severe obesity (CSO) is a surgically treated disease.The Roux-en-Y gastric bypass (RYGBP) has been used to treat patients with CSO and has resulted in an improvement in co-morbidities. We speculated that after a period of weight loss, patients would require less medication, resulting in cost-savings to both the patient and the insurance company, as well as an overall gain in health. Method: A retrospective study was performed which involved the first 100 patients who had undergone RYGBP at a community-teaching hospital. Analysis of the data was conducted by the Wilcoxon signed rank test. Results: 64 patients met our inclusion criteria and had adequate follow-up data available. The mean BMI was 57 kg/m² (range 36.6- 85.4 kg/m²), the female to male ratio was 4:1 (51:13), and the mean age was 44 years (range 27-64). The average monthly medication expenditure was reduced from $317 (SEM 47.25, range $23.12-$1801.19) preoperatively, to $135 (SEM 35.35, range $0.00-$1122.72) postoperatively. This reduction is significant (P <0.01). Conclusion: Weight loss after RYGBP leads to a significant reduction in medication expenses. These medication savings offset the costs of the initial procedure and represent permanent financial savings for the patient and society.     

Salvage of Failed Horizontal Gastroplasty by the Addition of a Distal Gastric Bypass

Thirty-one patients underwent conversion of a failed horizontal gastroplasty by addition of a distal gastric bypass. Twenty-seven patients had complete long-term follow-up and their data are presented. The patients were separated into three groups depending on the initial gastroplasty pouch sizes (varying between 25 and 60 ml). At the time of surgery stoma sizes were evaluated, some being found near 10 mm, others being smaller, that were debanded, and others larger that were not repaired. Follow-up after distal gastric bypass was 5.7 years (mean). Analysis of the weight loss data showed that the addition of a distal gastric bypass resulted in mean greatest excess weight losses near 80% for all groups. Over many years excess weight losses diminished but only one patient was a weight loss failure. Weight loss was best maintained and side-effects were fewest where the stoma size was near 10 mm. Pouch sizes themselves could not be positively correlated with weight loss, stoma size being much more important. Four patients had manifestations of the acid peptic ulcer diathesis and were effectively dealt with by means of vagotomy and hiatus herniorrhaphy.     

42-Month Preliminary Follow-up of the Silastic Ring Vertical Banded Gastroplasty

Background: The authors review preliminary experience with silastic ring vertical gastroplasty (SRVG). Methods: Of 202 patients who underwent SRVG, 191 are more than 3 months postoperation and of these 165 were accessible for review. Results: Pouch volume could not be readily measured. The TA90BN stapler was occasionally difficult to apply exactly at the angle of His. There was one subphrenic abscess, one gastric bleed, and one dehiscence. Vomiting occurred in eight patients who required reoperation: ring removal, three; cholecystectomy, one; conversion to vertical banded gastroplasty, one; conversion to Roux-en-Y gastric bypass, three. There was no mortality. Weight loss has been satisfactory to 42 months. Conclusion: SRVG has been a relatively simple operation, with acceptable morbidity and weight loss thus far.