Staple-line Disruption Following Vertical Banded Gastroplasty

Background: The purpose of this study was to determine the frequency with which staple-line disruption occurs following vertical banded gastroplasty (VBG) in morbidly obese patients, to investigate the effect of this complication on weight loss, and to identify any clinical symptoms that might be associated with staple-line disruption. Methods: From April of 1992 to June of 1994, 60 patients with morbid obesity underwent VBG. Double-contrast radiographic examination of the upper gastrointestinal tract was performed on all patients at 6, 12, 24, and 36 months postoperation to assess the integrity of the staple line. At these same times, the weight of each patient was measured, so that the patients found to have staple-line disruption could be compared to those without disruption in terms of weight loss. Results: Over the duration of the study, staple-line disruption was found in 12 patients (20%). All of these patients demonstrated satisfactory weight loss. Between the group of patients with staple-line disruption versus the group without disruption, weight loss did not differ significantly at any time up to 3 years postoperation. In addition, in the patients with staple-line disruption, no clear symptomatology that might be associated with this complication was discovered. Conclusions: Our results lead to the conclusion that small disruptions in the staple line lack clinical importance and do not significantly affect weight loss for at least the first 3 postoperative years. Furthermore, staple-line disruption does not seem to be associated with any specific clinical symptoms. Follow-up of all patients via barium meal is the correct approach for discovering the exact incidence of this complication.     

Radiological Investigations in Vertical Banded Gastroplasty Patients

In our Institute we have performed 124 vertical banded gastroplasties. Patients with a follow-up beyond 3 months were studied with a barium meal, in order to evaluate the efficiency of surgery and the eventual complications. Seventy-nine patients have had one or more X-ray investigations at various times after surgery (for a total of 136 studies). The first 20 patients were routinely studied at 1, 2 and 3 years after the operation; the next 32 patients were studied for features such as vomiting, poor weight loss or low food intake; the last 27 patients were studied with an early overlook beginning 3 months after surgery. We noted gastroesophageal reflux in eight (10.1%) cases, outlet dilatation in four (5%) cases, outlet substenosis (diameter 6-8 mm) in 13 (16.4%) cases, outlet stenosis (diameter ≤5 mm) in four (5%) cases, peanut-type deformation in three (3.7%) cases, and staple-line disruption in 17 (21.5%) cases. The staple-line disruption was correlated in the first part of the series with a reinforcement of such a suture, while the last 27 patients, with vertical stapling carried out with a 4-row stapler without reinforcement, did not present any disruption. The radiographic examination gives information about weight loss and side effects.     

Unusual Late-Onset Wernicke’s Encephalopathy Following Vertical Banded Gastroplasty

Wernicke’s encephalopathy (WE) related to bariatric surgery is the consequence of thiamine depletion occurring usually after restrictive surgical procedures with gastric outlet impairment causing frequent vomiting. We present a 35-year-old man with body mass index of 47.2 who developed a WE 7 years after a vertical banded gastroplasty. Late stenosis of the outlet due to gastric band inclusion was the precipitating mechanism. Poor compliance of dietary pattern and vitamin supplementation along with episodic vomiting both contributed to progressive symptoms of instable gait and mental changes. Magnetic resonance imaging confirmed the diagnosis of WE by showing hyperintense T2 signals at the mammillary bodies. Recovery of symptoms was possible after early thiamine therapy. Unusual late-onset symptoms and contributing factors to WE are discussed.     

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.     

Psychological Effects of Vertical Banded Gastroplasty on Pathologically Obese Patients

For a period of 2 years the authors have examined on 16 pathologically obese patients the psychological effects of the weight loss resulting from vertical banded gastroplasty. At the time of surgery the patients' average age was 41 years. The patients' average weight of 125.9 kg (range 110-150 kg) decreased after surgery to 89 kg, showing a decrease of 36.9 kg (range 20-69 kg). The postoperative compliance has been good despite the fact that the remaining gastric capacity allows for the ingestion of only 50-70 ml of food. Psychological results, obtained through consultations, semi-structured interviews and a series of tests, brought to light remarkable changes directly proportional to the weight loss achieved. Psychic well-being, self-esteem, and improvements in the interpersonal relations within the family and work environments represent in summary the positive results of the weight loss achieved by patients with no other possibility (voluntary) to keep their food intake under control (which we termed ‘food addiction’). The patients abandon their depressive traits and achieve a degree of confidence that preserves them from stress and anxiety. Patients improve their social mobility, and for many the sexual relations with the partner become more frequent and intense. The weight loss plays an indispensable role within itself but additionally is associated with a general normalization of all physical parameters. Also, it starts an avalanche of positive events which break the vicious cycle: aesthetic inadequacy-anxiety/depression-food-excess weight.     

Videolaparoscopic Vertical Banded Gastroplasty

Background: In June 1993, the authors started performing the Vertical Banded Gastroplasty (VBG) via laparoscopy. Methods: Since June 1993, 25 patients have undergone laparoscopic VBG. Results: Weight loss did not differ from the traditional open VBG. Conclusions: The laparoscopic procedure, which can be performed simply, permits minimal trauma compared to the traditional open operation, with a reduction in hospitalation and in short-term as well as long-term complications.     

Psychosocial Functioning,Personality, and Body Image Following Vertical Banded Gastroplasty

Background In addition to increased risks of morbidity and mortality, extreme obesity is substantially associated with psychosocial problems. Therefore, the ultimate goal of bariatric surgery should not only be reducing weight and counteracting comorbid conditions but also improving psychosocial functioning. In addition to being an important goal of bariatric surgery, enhanced psychosocial functioning may motivate patients to adhere to adequate health behavior to maintain the surgically established weight loss. Methods We evaluated early postoperative psychosocial functioning in several domains over time. Preoperatively as well as 6, 12, and 24 months after vertical banded gastroplasty, 104 patients were psychologically assessed using a semi-structured interview and psychological questionnaires focusing on psychosocial functioning, personality, and body image. Results Over time, we found significant changes in weight: 2 years excess weight loss was 58.6%. In addition, most aspects of psychosocial functioning showed significant improvements over time. However, initial improvements in depressive symptoms, sleeping problems, and neuroticism did not last. With respect to personality features, only short-term changes in self-esteem were found. The most robust improvements were seen in the case of body image. Finally, within the patient group, there was a wide variability in changes. Conclusion Vertical banded gastroplasty not only leads to considerable weight loss but also to significant improvements in psychosocial functioning. However, some improvements waned over time, and successful postoperative functioning did not apply to all patients.     

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.     

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%).     

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.     

Three-Year Results of Laparoscopic Vertical Banded Gastroplasty

Background: Despite the development of pharmacologic agents for the treatment of massive obesity, surgery remains the only treatment option that has been shown to offer long-term weight reduction. 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 (lap VBG) in 60 obese patients. Patients and Methods: 60 massively obese patients (50 female) with a mean ± SEM body mass index (BMI) of 44.4 ± 1.0 kg/m² were followed up prospectively for an average of 23.0 ± 1.5 months. Lap VBG 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. The patients were seen postoperatively 2, 6, 12, 24, and 36 months after surgery. Results: Conversion to open surgery was performed in 15 cases. Preoperative median BMI and postoperative hospital stay were higher in the open group than in the laparoscopic group: 47.8 kg/m² (37.7-65.7) and 5 days (3-13), and 41.9 kg/m² (32.5-57.3) and 3 days (2-6), respectively (P < 0.01 for both). After 36 months of follow-up, the median BMI was 36.9 kg/m² (24.6-50.7) (n = 9) in the open group and 37.0 kg/m² (25.8-53.3) (n = 14) (NS) in the laparoscopic group. The number of conversions to open surgery and the median operating time were higher in the first 30 cases than in the last 30 cases: 11 and 137.5 min (96-225) and 4 and 115.0 min (85-190), respectively, with similar preoperative BMI: 44.1 kg/m² (33.8-65.8) and 41.2 kg/m² (32.4-57.8). Conclusions: Lap VBG can be performed safely and results in a shorter postoperative stay than does open surgery. Weight loss was maintained over the 3-year follow-up period. There is a learning curve, resulting in fewer conversions to open surgery and shorter operating time. Long follow-up studies are needed to ascertain that long-term weight loss equals that of open VBG.     

Revisional Surgery After Failed Vertical Banded Gastroplasty: Restoration of Vertical Banded Gastroplasty or Conversion to Gastric Bypass

Background: An increasing number of patients with a failed primary bariatric procedure present themselves for secondary treatment. Only a few studies have investigated critically the success of revisional surgery. In the present study, the effectiveness of revisional surgery for failed vertical banded gastroplasty (VBG) is analyzed: restoration of the VBG (reVBG) is compared to conversion to a Roux-en-Y gastric bypass (RYGB). Patients and Methods: From 1980 to 1996, 136 consecutive morbidly obese patients underwent primary RYGB (n = 20) or VBG (n = 16). Weight loss, indications and complications after revisional surgery were registered. The rate of revisional surgery after primary and secondary bariatric procedures was estimated by means of a Kaplan-Meier analysis. Results: Kaplan-Meier analysis revealed that 56% of the patients will eventually require revisional surgery after initial VBG over a 12-year period compared to 12% after initial RYGB (P < 0.01). After reVBG 68% will need revisional surgery over a 5-year period, while no further revisional surgery was required after conversion to a RYGB (P < 0.05). Body mass index dropped significantly after reVBG or conversion to RYGB for insufficient weight loss (P < 0.05), however, more revisional surgery was necessary after reVBG to achieve this result. The complication rate was comparable between reVBG and conversion to RYGB (33%). Conclusion: Conversion of a failed VBG to a RYGB is more effective than a reVBG, because conversion to RYGB provides satisfactory weight loss without requiring further revisional surgery.     

“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.     

Psychosocial Predictors of Success After Vertical Banded Gastroplasty

Background  Psychosocial and behavioral factors contribute to successful postoperative outcomes. Patients’ psychological factors may be predictive of postsurgical adjustment. The identification of these factors would allow targeting patients at risk of a poor outcome. Furthermore, it would enable better patient selection and preoperative and/or postoperative counseling to improve long-term outcomes. Unfortunately, no such consistent and reproducible predictors have been found so far. Methods  The present study investigated in morbid obese patients who underwent vertical banded gastroplasty (VBG) the predictive value of preoperative parameters, especially health-related quality of life (HRQoL), personality, psychosocial functioning, body image, and eating behavior for 2-year changes in these variables, as well as weight loss. Results  Two years after VBG, patients had significant weight loss and reported improvements in physical HRQoL, personality and psychosocial functioning, body image, and eating behavior. Although we were not able to find psychosocial predictors of excess weight loss or excess body mass index loss 2 years after VBG, we did find psychosocial predictors of 2-year changes in HRQoL, personality and psychosocial functioning, body image, and eating behavior. Conclusion  Preoperative psychological assessment may not be necessary with respect to weight loss. However, it is helpful in targeting patients at risk of poor psychological outcomes after VBG.     

Vertical Banded Gastroplasty in the Severely Obese under Age Twenty-One

Background: The severely obese under 21 years of age are at high risk of missing normal development during a crucial period of life and should be considered for surgical treatment. Vertical banded gastroplasty allows patients to be treated effectively while continuing to have normal digestion and absorption without the risks of complex operations. Methods: This was a retrospective outcome review of 47 severely obese who were under age 21 when surgically treated with VBG. Results: There were no operative mortalities, leaks, or wound infections. Body mass index in 25 patients followed 5 years decreased from an average operative 48.1 to 36.2 kg m⁻². Equally for 14 patients followed 10 years, BMI decreased from an average operative 49.6 to 39.2 kgm⁻². Both patient groups had 74% follow-up. Conclusions: Sustained weight reduction improved general health and allowed participation in life activities that would otherwise not have been possible. Adherence to recommended operative technique and intraoperative measurement of pouch volume is necessary to avoid excessive enlargement of the pouch, with resulting weight gain, reflux, and need for revision.     

Laparoscopic Conversion of Vertical Banded Gastroplasty (Mason MacLean) into Roux-en-Y Gastric Bypass

Background Revision of bariatric procedures is required in 10 to 25% of patients either for insufficient weight loss or for complications. Patients undergoing vertical banded gastroplasty (VBG; Mason MacLean) may require revision in up to half of the cases in the long term. Roux-en-Y gastric bypass (RYGBP) is considered the procedure of choice for revision of VBG gastroplasty. Patients and Methods Eighteen patients, 16 women and 2 men with a mean age of 41.7 years (range 27–72) and a mean BMI at 37.6 kg/m² (range 22.5–47), underwent laparoscopic conversion of VBG into RYGBP. Indications for revisional surgery were insufficient weight loss (11 patients), stoma stenosis (4 patients), and acid reflux (3 patients). Results Operative time was on average 203 min (range 60–300 min), and conversion was required in one patient (5.5%). There was no early postoperative mortality, and four patients (22.2%) developed immediate postoperative complications (gastrojejunostomy leak 1; stenosis of the gastrojejunal anastomosis 2; liver abscess 1). One patient died 6 months after conversion because of a bleeding anastomotic ulcer (late mortality 5.5%). Two patients (11.5%) developed late complications (incisional hernia 1; internal hernia 1). At a mean follow-up of 23, 4 months BMI is on average 29.8 kg/m² (range 22.7–37). Conclusion Although revision of failed VBG into RYGBP gives good functional results, the risk of postoperative serious complications must be carefully evaluated before revision.     

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.     

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.     

Gastric Mucosal Changes following Gastroplasty: A Comparative Study between Vertical Banded Gastroplasty and Silastic Ring Vertical Gastroplasty

Background: Long-term changes of gastric mucosa following surgery for morbid obesity have never been studied, to the best of our knowledge. As 31 patients in our series presented with various gastro-intestinal complaints following surgery, we used this opportunity to study mucosal changes. Methods: Thirty-seven gastroscopies were performed on 31 patients, 20 patients following Vertical Banded Gastroplasty (VBG) and 11 patients following Silastic Ring Vertical Gastroplasty (SRVG) with various gastrointestinal complaints. Macroscopic appearance of the gastric mucosa was examined and biopsies taken from the proximal gastric pouch, the transitional zone and distal stomach. Results: In most patients, macroscopic appearance of the proximal and distal pouches was normal. Pathological findings were mainly located in the transitional zone and were found mainly in the VBG group. Conclusions: This study indicates that damage to the gastric mucosa is related to the surgical technique, and mainly to the strip of mesh used in the VBG patients. Since hyperplasia and metaplasia were among the microscopic findings, a question is raised about the possibility of malignant transformation. We suggest that routine post-operative gastroscopies be considered, especially following VBG.     

Resolution of Diabetes Following Vertical Gastroplasty in Morbidly Obese Patients

Case reports are presented on three patients treated for morbid obesity by vertical gastroplasty. Prior to surgery the patients had diabetes which required insulin, up to 200 units per day, or oral hypoglycaemics for its control. Six months after surgery the diabetes had been resolved in all three patients, and they were no longer dependent on medication. Subjective reports from the patients suggests that their quality of life improved significantly.