Determinants of weight loss after vertical banded gastroplasty

Weight loss after gastric partition is highly variable even when the operation itself has been successful. We studied changes in body composition in relation to energy expenditure before and one year after surgery in one woman and five men, age 20-38 years, and BMI 42-62 kg/m2. Observations were performed shortly before, and 6, 12, 27 and 54 weeks after surgery. Body composition was measured with hydrostatic weighing and isotope dilution, and energy expenditure over 24 h (24EE) and during complete rest (sleeping metabolic rate (SMR)) with a respiration chamber and in five of the six subjects under daily living conditions over two-week intervals with doubly labeled water (average daily metabolic rate (ADMR). Weight loss and fat loss over the full observation period until 54 weeks after surgery was 54 +/- 8 and 43 +/- 9 kg (mean +/- s.e.m.), respectively. There was a more than three-fold difference in fat loss between the subject losing most, i.e. 70 kg, and the subject losing least, i.e. 20 kg. Fat loss was not related to initial fat mass in this group of six subjects but there was a significant negative relation with the loss of protein mass. There was a strong negative relation between fat loss and activity level of the subjects expressed as the quotient ADMR/SMR. These results show the contrary from what would be expected. Reduction of fat mass after successful gastric partition is highest in those subjects having the lowest physical activity level (before and) after surgery; these subjects lose less fat-free mass.     

The role of endoscopy after vertical banded gastroplasty.

Since 1984, a total of 99 patients underwent vertical banded gastroplasty (VBG) through protocol (pouch 8 ml in size, band 4.3 cm in circumference) to treat morbid obesity. Follow-up was obtained in 95 patients. Thirty upper gastrointestinal endoscopies were performed post-operatively in 17 patients. Indications were nausea/vomiting in 11, epigastric pain in 4, acute obstructive symptoms in 4, and miscellaneous in three. Findings included food impaction in 10, distal esophagitis in 8, gastritis in 4, and a normal examination in 2. Only 4 of 10 food impactions were associated with an excessively narrowed gastroplasty outlet. Eight patients had an excessively narrowed gastric stoma: two became asymptomatic with dietary modification only and six underwent dilation therapy (dilator range from 8 to 18 mm in diameter) with immediate resolution of symptoms in four of six. One of the two patients unresponsive to dilation was lost to follow-up, and the other required surgical revision after multiple dilation sessions.     

Gastroplasty procedures, particularly vertical banded gastroplasty

Vertical banded gastroplasty (VBG), the most frequently performed restrictive procedure to control severe obesity, was developed by Mason in 1982. The procedure evolved from experiential trials of earlier concepts and the timely availability of instrumentation to allow stapled vertical partition of the stomach. Success requires precise technical mastery and optimal patient compliance to provide permanent governance of satiety. The objective of weight control--to reverse co-morbidities of obesity, while causing minimal metabolic deficiencies--has been achieved in a wide selection of patients. The super-obese may be a group whose needs fall beyond the control of the VBG. Vertical ringed gastroplasty (VRG) performs similarly to VBG. Other types of gastroplasty have yet to prove reliable over time. Laparoscopic banded gastroplasty is reversible, adjustable and attractive to patients. Laparoscopic VBG must prove equivalent technical precision to that of open procedures before it can be useful. Deterrents to success such as staple-line failure, band erosion, behavioural backsliding, lack of teeth, large pouch syndrome and a super-obese candidate underscore the tenacity of severe obesity, the disease, as an adversary. Control, not cure, is possible.     

Anatomic, motor, and clinical assessment of vertical banded gastroplasty

The aim of this study was to assess gastric anatomy, motility, and emptying after vertical banded gastroplasty and to correlate the anatomic and physiologic results with clinical outcome. Eleven patients were studied at least 7 mo after operation, by which time they had lost 31% +/- 4% (mean +/- SEM) of their excess body weight. Stomal diameter, volume, and distensibility of the proximal gastric pouch were determined by a balloon distention technique. Gastric emptying was monitored scintigraphically both with and without distention of the proximal pouch. Stomal diameters ranged from 10 to 15 mm (mean +/- SEM = 11 +/- 1 mm), and pouch capacity ranged from 20 to 150 ml (76 +/- 9 ml). Mean intrapouch pressure was 13 mmHg before distention, increased to 22 mmHg with distention to half-maximal capacity, and then changed little with further distention to maximum capacity. Near maximal pouch distention during gastric emptying of a 300-ml test meal decreased antral contractile activity and speeded the initial rate of emptying (t25 with distention = 14 +/- 3 min vs. 24 +/- 3 min without distention, p less than 0.03), but did not alter the later rate of emptying. No clear-cut relationship was present between weight loss and stomal diameter, pouch volume, or gastric emptying. The conclusion was that distention of the proximal gastric pouch created by vertical banded gastroplasty inhibited antral contractions and increased the initial rate of gastric emptying, but no clear-cut correlation was found in this cohort between weight loss after the operation and stomal diameter, pouch size, and gastric emptying.     

Horizontal or vertical banded gastroplasty after pretreatment with very-low-calorie formula diet: a randomized trial

Horizontal and vertical banded gastroplasty (GP) were compared as to their effectiveness and side-effects in patients pre-treated for morbid obesity with a very-low-calorie formula diet (VLCD). The pre-treatment served to select the compliant patients, to minimize the surgical hazard, and to optimize the total weight reduction. Seventy-four consecutive patients (median age 34 years, median body weight 125.1 kg, and median overweight 93 per cent) were included according to the criteria for entry. The median weight loss on VLCD was 25.7 kg (range, 5.8-92.6 kg) and the median overweight reduction reached 46 per cent of the initial overweight (range, 9-83 per cent). Only few and mild side-effects were observed. Sixty-nine per cent of the patients fulfilled our criterion for surgery by reducing their initial overweight by at least 40 per cent. Of these, 23 and 22 patients were assigned respectively to either vertical banded or to horizontal GP. Patients and dietitians were not informed of the assignment. A significant weight loss occurred in both groups. Three months after surgery weight loss after vertical banded GP proved to be the larger (P less than 0.001). The difference became even more pronounced due to an earlier regain among patients treated with the horizontal GP. Thus, at 12 months, the net weight loss after surgery was 9.7 kg (range, -28.2-28.7 kg) in the vertical banded GP group and -1.0 kg (range, -15.0-36.5 kg) in patients treated with horizontal GP (P less than 0.0005). At this time, the total weight loss in the groups was 48.5 kg (range, 6.4-104.0 kg) and 32.6 (range, 3.7-125.1 kg) respectively (P less than 0.02), and the total reduction of overweight was greater in the group treated with vertical banded GP (80 per cent (range, 10-96) versus 56 per cent (range, 8-92), P less than 0.005). There were no deaths, and side-effects to VLCD as well as to GP were generally mild. It is concluded that vertical banded GP is more effective than horizontal GP and that the former operation adds a significant weight loss to that obtained by VLCD. The combined treatments offer a weight reduction comparable to that observed after jejunoileal bypass. However, some regain within 1 year makes it questionable if the vertical banded GP is sufficient to prevent weight regain.     

The conversion of a horizontal to vertical banded gastroplasty: a hazardous procedure

This paper presents 18 cases of failed horizontal gastroplasty from the combined experience of St. Joseph's Health Centre in Toronto and Royal Victoria Hospital in Montreal, who had vertical banded gastroplasty as the remedial operation to correct weight gain after horizontal gastroplasty.     

A randomized comparison of horizontal and vertical banded gastroplasty: what determines weight loss?

Pouch volume, stoma diameter, and pouch emptying rate were measured postoperatively and after 6 months in 45 morbidly obese patients who had been assigned to either horizontal gastroplasty (HGP) or vertical banded gastroplasty (VBGP) after pretreatment with diet alone. Pouch volume and stoma diameter were measured by a standardized radiographic method with blinded assessment by two observers. Pouch emptying rate was determined by a standardized scintigraphic method and expressed as the mean transit time (t60). Pouch volume and stoma diameter did not change, whereas t60 decreased by 36% during the first 6 months after HGP (p less than 0.001). Pouch volume was larger after HGP (p less than 0.001). Pouch emptying was faster after VBGP (p less than 0.001), but these patients had the better weight loss (p less than 0.001). Variation in weight loss after either operation was unrelated to pouch volume, stoma diameter, and t60. Stoma diameter was not correlated with t60. The study provides further evidence against the significance of stoma diameter and pouch emptying rate as determinants of weight loss after gastroplasty. The much smaller pouch volume after VBGP may favor weight loss.     

Impaired glucose metabolism and health related quality of life

AimsWe aimed at investigating whether different categories of glucose tolerance have any effect on a person's HRQoL.MethodsPopulation-based cross-sectional study conducted as a community sample of apparently healthy middle-aged individuals living in Western Finland. The subjects of the study, 1383 individuals, aged 45–70 years, had at least one cardiovascular risk factor but no previous diagnoses of either diabetes or cardiovascular disease. They completed health related quality of life (HRQoL) questionnaire before the oral glucose tolerance test (OGTT) was performed to diagnose the gategories of glucose tolerance.ResultsPersons with newly diagnosed type 2 diabetes (NDM) had lower scores for physical functioning, general health and emotional role than subjects with normal glucose tolerance.ConclusionThe results of the HRQoL questionnaire demonstrated that NDM is negatively associated with HRQoL, but prediabetes – IFG or IGT – does not.     

Vertical banded gastroplasty for the treatment of morbid obesity

We report the technique and results of vertical banded gastroplasty in 86 morbidly obese patients. At 12 months, the patients had lost a mean of 57% of their excess body weight; 36 months, they had lost 70%. The most severe early complication was perforation of the esophagus. Other complications included disruption of the vertical staple line in three cases and migration of the mesh band. We were able to achieve satisfactory weight reduction in all patients over a period of 36 months. In view of the good results, reduced morbidity, and absence of mortality, we feel that vertical banded gastroplasty is the surgical treatment of choice for morbid obesity at present.     

Endoscopic therapy for main pancreatic-duct rupture after Silastic-ring vertical gastroplasty

BACKGROUND: Acute pancreatitis with pancreatic-duct rupture and fluid collections is a rare complication after Silastic ring vertical gastroplasty. It can be attributed to pancreatic trauma occurring during surgery. METHODS: Endoscopic therapy with transmural drainage of collections was performed in 4 patients who had undergone Silastic ring vertical gastroplasty and who had presented with acute pancreatitis with main pancreatic-duct rupture at the body of the pancreas. OBSERVATIONS: All patients had successful transmural drainage with cystogastrostomy, followed by stent insertion. Only one patient had a late recurrence because of stent migration. The major difficulty was related to positioning of the endoscope and the possible need of pneumatic dilation of the outlet channel to reach the puncture site. CONCLUSIONS: Endoscopic therapy is useful in acute pancreatitis with pancreatic-duct rupture after Silastic-ring vertical gastroplasty and, although technically difficult, could be considered as a first-line approach in the management of these patients.     

Marlex mesh erosion: a complication of horizontal banded gastroplasty

One-hundred and thirty-eight obese patients underwent horizontal banded gastroplasty. The stoma in each case was reinforced with Marlex mesh. Fifty of these patients developed upper gastrointestinal symptoms sufficiently severe to require endoscopy. At endoscopy 12 were found to have erosion of the Marlex mesh into the stoma. Mesh erosion was found at various intervals postoperatively ranging from 5 weeks to 55 months with a mean of 23 months. Nine of the 12 had associated stenosis of the stoma and three had dehiscence of the staple line. There were no symptoms peculiar to Marlex erosion. Seven patients required surgical revision of the stoma, four were treated medically, and one was treated with a combination of stomal dilation and medical therapy.     

Vertical banded gastroplasty in the treatment of morbid obesity: results of three year follow up.

Vertical banded gastroplasty has replaced jejunoileal bypass in the surgical treatment of morbid obesity. Although this procedure carries a low incidence of early postoperative complications there is little information on either longer term follow up or the impact on nutritional status. The present study describes the outcome in 42 patients with morbid obesity who underwent vertical banded gastroplasty and were followed up in a special nutrition clinic between nine and 36 months postoperatively. Body mass index (BMI) fell from a preoperative value of 47.4 (6.7) kg/m2 (mean (SD] to 37.5 (5.8), 35 (6.2), 33.9 (6.1), and 33.1 (5.7) kg/m2 at 6, 12, 24, and 36 months respectively. Immediate postoperative complications were minimal but during follow up four patients developed stenosis of the gastroplasty stoma and required reoperation. Plasma albumen concentrations were maintained but three patients developed iron deficiency anaemia. Most patients were able to eat a normal diet in reduced quantities and noted a marked improvement in the quality of life. The benefits and safety of vertical banded gastroplasty suggest an important role for this operation in the management of morbid obesity.