Laparoscopic Vertical Banded Gastroplasty: The Milwaukee Experience

Background: laparoscopic techniques are being developed for bariatric surgery. Methods: eleven morbidly obese patients underwent laparoscopic vertical banded gastroplasty in 1993-1994. Results: average length of hospital stay was 3.9 days, mean operating time was 202 min, and the average hospital charges were $12 800. These numbers were compared to the most recent open gastric bypass patients, where average length of stay was 7.4 days, mean operating time was 105 min, and the average hospital charges were $9800 (adjusted value of $16 700). There were no post-operative complications in the laparoscopically-performed VBG patients. Conclusion: laparoscopic VBG is feasible and cost-saving. Weight loss and long term results await ongoing follow-up.     

Gastrointestinal Complications after Vertical Banded Gastroplasty

Background: Gastric surgical procedures for morbid obesity may have occasional serious complications. The vertical banded gastroplasty according to Mason's technique (VBG) is a common procedure for morbid obesity. The aim of this study is to present the complications in the gastrointestinal (GI) tract after VBG and to discuss their treatment. Methods: In this study 260 morbidly obese patients (62 males and 198 females) underwent VBG. Results: Complications in the GI tract were encountered as follows: narrowing of the communicating lumen of the two parts of the stomach in four patients, dehiscence of the vertical stomach staple line in three patients, cholelithiasis in 12 patients, gastric perforation in four patients, postoperative fistulas in three patients, serious hepatic failure in one patient, significant gastritis and esophagitis in 32 patients, intestinal obstruction in five patients and frequent prolonged vomiting in 23 patients. The authors attempted to treat all these complications conservatively. In 22 patients, however, a new procedure was necessary. In some cases a partial gastrectomy was necessary. Conclusion: VBG is considered to be a satisfactory procedure for weight loss in morbid obesity, but has occasional complications from the GI tract, besides the complications from the other systems. Thus, this procedure should be performed only when absolute indications exist.     

Vertical Banded Gastroplasty vs Gastric Bypass: 10 Years follow-up

In 1982, a prospective study to evaluate and compare the operations for treatment of morbid obesity, vertical banded gastroplasty (VBG) and gastric bypass (GBP), was carried out at the Center for Surgical Treatment of Obesity in Los Angeles. The VBG was performed as described by Dr Mason with a 5.0 cm circumference Marlex band. The GBP was the horizontal GBP with ≤ 50 cc pouch as described by Mason and modified by Printen and Griffen. One hundred patients had the VBG and 100 had the GBP. At 10 years follow-up, only 43 of the VBG patients and 46 of the GBP patients can be found. The groups are compared as to the perioperative complications, late complications and weight loss. VBG compared favorably with GBP for control of morbid obesity. GBP yields better weight loss and maintenance at all times of follow-up. Both procedures are equal in terms of morbidity and mortality.     

Staple Disruption in Vertical Banded Gastroplasty

Background: In earlier studies of vertical banded gastroplasty (VBG), staple-line disruptions (SD) were only reported in a few per cent or less. Two recent studies have shown a significantly higher frequency of SD. To find the true frequency of SD, all patients must be examined regardless of weight outcome. Methods: 91 consecutive patients were examined by a standardized radiological method at different postoperative intervals ranging from 6 to 48 months. Results: 41 out of 91 patients developed SD. The average diameter of the disruptions was 6 mm (range 2-16 mm). During the first 2 years of followup, when at least 31% of the patients had developed SD, there was no significant difference in weight loss between the group with SD and the group without SD. Conclusion: SD is an inherent problem of VBG which has been underestimated for a long period of time. An SD frequency of 45% or more within the first few years is not acceptable and changes in the VBG technique must be considered.     

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.     

Vertical Banded Gastroplasty at More than 5 Years

Background: Optimal evaluation of the results of surgery for morbid obesity requires a long-term follow-up for at least 5 years. Methods: One hundred patients were operated by vertical banded gastroplasty (VBG) and revised with a follow-up of no less than 5 years. Sixty patients were morbidly obese with a body mass index (BMI) of between 40 and 50 kg/m², and 40 were superobese with a BMI of >50 kg/m². Follow-up included 93 patients (93%). Results: Initial surgical mortality was nil. Twenty-five patients required surgery for complications related to the technique (25%) and one patient died due to pulmonary embolism after a re-stapling operation. The percentage excess weight loss was 54.3%, and the BMI was 33 kg/m² for the 84 patients followed to 5 years post VBG. Only 40 out of 92 patients (43.5%), obtained the weight loss benefit due to the operation. None of them is able to eat a regular diet, and the quality of food intake has been severely affected in some of them. Conclusions: VBG is, in our experience, a safe and technically simple operation, but the long-term results are questionable. The reoperation rate was high, and weight loss and quality of life are superior with other operations.     

Long-Term Results of Vertical Banded Gastroplasty: Marlex versus Dacron Banding

Background: The VBG was originally performed with a Marlex band and characterized by a satisfactory weight loss and low morbidity. The effect of the material used for the banding procedure (Marlex vs Dacron) in vertical banded gastroplasty (VBG) is evaluated. Methods: In 49 consecutive obese patients treated with a VBG, a Marlex band was used in 17 patients and a Dacron band in 32 patients. Data were analyzed retrospectively with regard to the type of band, weight loss and complications. Results: A significant difference was found in the percentage excess weight 5 years postoperatively in favor of the Dacron group (59.2% vs 39.2%; p < 0.05) because of more band-related complications in the Marlex group. The difference in percentage excess weight disappeared 8 years postoperatively (43.3% vs 46.8%), due to the renewed weight loss of the Marlex group following reoperation. Conclusion: The Dacron band is superior to the Marlex band in VBG because sustained weight loss is satisfactory and morbidity is low.     

Divided Vertical Banded Gastroplasty Either for Correction or as a First-Choice Operation

Background: Staple-line disruption may occur after vertical banded gastroplasty (VBG). Methods: Since May 1996, the authors have performed the gastric restrictive procedure divided VBG, as described by MacLean, as a first-choice operation and not only as correction for staple-line breakdown. Divided VBG was done in 111 patients, 32 as correction after staple-line disruption and 79 as a first choice, 29 of them by hand-assisted laparoscopy with the dexterity pneumosleeve. Results: Weight loss and nutritional status have been very satisfactory. Operating time for the standardized operation has been no longer than 60 minutes. Conclusion: Divided VBG, especially if done by hand-assisted laparoscopy using the dexterity pneumosleeve, is a valid restrictive procedure.     

Erosion of Marlex Mesh Collar after Vertical Banded Gastroplasty

Marlex mesh, as opposed to silastic ring, when used as a collar in the bariatric procedure of vertical banded gastroplasty, has been reported rarely to erode into the gastric lumen. We report two cases of such an erosion, of which one ended as a complete internalization of the collar into the stomach. In one of the patients we observed a wider than expected portion of tissue that had been encircled by the collar, which might have caused a local inflammatory reaction leading to the later erosion.     

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

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

Nutrient Intake following Vertical Banded Gastroplasty or Gastric Bypass

Background: This study explored eating habits, nutrient intake, and blood vitamin and mineral levels to determine whether severely obese subjects (BMI 40-50 kg m⁻²) post-vertical banded gastroplasty (VBG) or gastric bypass Roux-en-Y (GBR) are at risk of developing compounded under-nutrition. Methods: A dietary follow-up of 36 VBG and 19 GBR was maintained for 18 months via 7-day food intake diaries and 24-h recalls. Food intake was analysed for energy and nutrient composition and for its relative amount to recommended dietary allowances (RDA). Results: Weight loss was greatest during the first 6 months, continued at a slower rate for the next 6 months, nearly ceasing thereafter. The results following GBR were not substantially different from those following VBG 18 months postoperatively. The median weight loss at 1 year postoperatively was 48, 46, 48 and 36 kg; expressed as residual excess body weight: 0.2, 16, 13 and 22% for GBR Men, Women, VBG Men, Women, respectively. According to the classification proposed by Reinhold, all subjects achieved excellent treatment outcomes 18 months postoperatively. Despite the relatively low reported energy intake (20-50% below RDA), no correlation was found between rate of weight loss and energy intake at 6 months postoperatively. The intake of most vitamins and minerals was below 50% of RDA during the 18 months follow-up. The increase in energy intake did not improve the level of the nonenergy-contributing nutrients. Compliance to multivitamin and mineral supplement intake deteriorated with time. Conclusion: The low to within-normal range of blood vitamin and mineral levels 12 months postoperatively suggests the slow development of subclinical nutritional deficiency which could jeopardize the subjects' long-term health status.     

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.     

Vertical Gastroplasty with Artificial Pseudopylorus: Analysis of 106 Cases

Background: Between January 1991 and December 1994, 106 consecutive morbidly obese patients (19 males and 87 females) underwent Vertical Gastroplasty with Artificial Pseudopylorus (VGAP). Methods: The mean age of the patients was 34 years (range 20-58), the mean percent excess body weight 122% (range 80-234), and the mean Body Mass Index (BMI) 51 kg/m⁻² (range 41-81). The technique of gastroplasty was relatively simple, avoiding the creation of the circular stapled window and the mesh banding of the outlet. The partition of the stomach was done by the use of three double-row staplers vertically downwards from His angle parallel to the lesser curvature of the stomach. The pseudopylorus was constructed by the use of two bands of silk No. 0, which were completely covered by stomach seromuscular coat. Results: Percent excess weight loss (± sd) on the 3rd, 6th, 18th, 24th, 36th and 48th month postoperatively was 32 ± 10, 51 ± 12, 71 ± 12, 78 ± 12, 82 ± 9, 80 ± 11 and 81 ± 10 respectively. Postoperative mean BMI (± sd) at the same times were 40 ± 7, 34 ± 7, 29 ± 6, 27 ± 5, 28 ± 3, 28 ± 4 and 28 ± 3 respectively. The early complication rate was 4.7% and the late, including incisional hernias, 6.6%. One patient (0.9%) died of massive pulmonary embolism. Conclusion: VGAP is a relatively simple and safe method which gives satisfactory results in body weight reduction, and avoids some complications of the other forms of vertical gastroplasty.     

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.     

Complications After Vertical Gastroplasty with Artificial Pseudopylorus in the Treatment of Morbid Obesity: A 7-Year Experience

Background: Vertical gastroplasty with artificial pseudopylorus (VGAP) was designed to reduce the complication rate of other forms of gastroplasty. The purpose of this study was to analyze the complications of this approach for 7 years of surgical practice. Methods: A total of 156 morbidly obese patients (BMI 41-81 kg/m²) who underwent VGAP were analyzed retrospectively in terms of early and late complications and gastroplasty failure. Results: The early complication rate, operative and systemic, was 6.40% (10 patients) and the late complication rate was 12.16% (19 patients). Early complications: We observed two gastric leaks and subphrenic abscess formation with one gastrocutaneous fistula, one severe intraabdominal hemorrhage, one evisceration, two serious wound hematomas, one lobar pneumonia, one massive pulmonary embolism and two nodular erythemas. Late complications: There were two prepyloric ulcers, one pseudopyloric ulcer with stoma stenosis, seven wound hernias, four pseudopyloric dilatations with suture rejection and gastroplasty failure, and five staple-line dehiscences with endostomach channel formation and gastroplasty failure. One patient (0.64%) died from massive pulmonary embolism. Conclusions: The early and late complication rate was acceptable in this series. The applied technique of VGAP is simple, safe, and helps avoid many complications caused by the other forms of gastroplasty.     

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.     

Vertical Banded Gastroplasty with Adjustable Silicone Band: Preliminary Experiences

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

Changes in Esophageal Function after Vertical Banded Gastroplasty as Demonstrated by Esophageal Scintigraphy

Background: The effects of surgery for morbid obesity on the function of the upper gastrointestinal (GI) tract are of interest to bariatric surgeons. This study was undertaken to determine any changes in esophageal function, following vertical banded gastroplasty (VBG) in morbidly obese patients, as detected by esophageal scintigraphy. Methods: Ten consecutive morbidly obese patients (six female and four male) underwent preoperative esophageal scintigraphy and upper GI endoscopy. These investigations were repeated 12 months after VBG to coincide with expected appreciable weight reduction. The results were tabulated together with body mass indices, crude weights and percentage excess weight lost. Results: Before VBG one patient gave a history of mild heartburn, one had mild dyspepsia and the remaining eight patients had no GI symptoms. No patient had a hiatus hernia or endoscopic evidence of reflux esophagitis. Preoperatively all patients had abnormal scintiscans. The abnormalities were esophageal retention (all) and intraesophageal reflux (five out of 10 patients). Gastroesophageal reflux was not identified in any patient. Postoperatively scintiscans were normal or improved in six out of 10 patients and unchanged in four out of 10 patients. In three patients the scans were normal and three showed overall improvement in esophageal function, although in one of these latter patients gastroesophageal reflux was observed. Conclusions: In this series of morbidly obese patients, esophageal function as assessed by scintigraphy was abnormal. Following VBG it improved in six out of 10 patients and was unchanged in four out of 10. However, in one patient, who had shown an overall improvement in esophageal function, gastroesophageal reflux was demonstrated when it had not been seen preoperatively. This was asymptomatic. Thus, adverse changes in esophageal function after VBG were uncommon.