Adolfo Z. Fernandez and Eric J. DeMaria Introduction
The evolution of morbid obesity surgery has been directed by an effort to minimize complications while improving weight loss and reducing obesity comorbidities. Two different types of procedures have developed, simple and complex. Simple procedures include all restrictive procedures like the horizontal gastroplasty (HG), the vertical banded gastroplasty (VBG), or the adjustable ring gastroplasty. Complex procedures entail those that bypass segments of the gastrointestinal tract like the jejunoileal bypass, biliopancreatic diversion and the gastric bypass procedure (GBP). The complex procedure obtains better weight loss at the cost of more complications. Of all these, the most commonly performed are the GBP and the VBG— the current gold standards of bariatric surgery in their respective classes.
Surgeons will argue the superiority of GBP versus VBG and vice versa. VBG does not produce as much excess weight loss as the GBP, nor is it as durable. VBG does produce adequate weight loss improving the patient's obesity comorbidities. VBG is technically simpler to perform, offers less risk of micronutritional deficiencies, and maintains the continuity of the gastrointestinal tract. Furthermore, the VBG is considered a less morbid procedure, though some will argue to the contrary. The major disadvantage is that patients can regain the weight lost with the VBG by simple alterations in their diet. Foods that are high in fat and carbohydrates while low in volume are the main culprits. These same foods tend to cause a dumping syndrome in GBP patients and "protect" them from regaining unwanted weight. Overall, the choice between which procedure to perform depends on the surgeon's experience and comfort with the procedure.
The horizontal gastroplasty (Fig. 8.1) was introduced by Printen in 1973. The initial procedure failed to produce significant weight loss because of a large pouch and easily dilated stoma. In 1979 Gomez published a modification of the horizontal gastroplasty with a smaller pouch and reinforced stoma. This modification did not achieve much success. The stoma obstructed early and often. The reinforcement stitch occasionally eroded into the lumen leading to stoma dilatation and weight gain. The horizontal gastroplasty failed to achieve adequate weight loss and reduction of any of the obesity-related morbidities.
In 1976, Tretbar first introduced the concept of a vertical pouch. He named this procedure the fundal exclusion. In this procedure, the fundus, the most compliant and expandable portion of the stomach, was excluded from the satiety process. The
procedure had some success, but the success was limited by the pouch and stoma size. The prior experience with the horizontal gastroplasty and the fundal exclusion led to the development of the VBG. Mason first described it in 1982 (Fig. 8.2). Since then, multiple modifications have been reported including variations in the band, stoma size, pouch size, and stomach partition. Many feel that slight variations in these can affect the amount of weight lost or the morbidity of the procedure.
The three most important components of the VBG are the band, the pouch and the stomach partition. Many authors have varied the size and composition of the band. Gore-Tex, Marlex, silastic, silicone, and adjustable bands have been used with varying degrees of success. Suter found that there was a significantly higher incidence of complications with silastic and adjustable bands when compared with Marlex mesh bands. The latter two tended to produce more obstructive type complications requiring re-operation. Ashley had a greater rate of stenosis and vomiting with GoreTex bands, compared to Marlex bands. One confounding variable was that the GoreTex bands were smaller than the Marlex bands. Naslund used a silicone band and had a 31% rate of complications including stomal stenosis, esophagitis, band erosion and staple line breakdown. Mason exclusively used the Marlex bands stating that the Marlex became incorporated into the neck of the VBG, thus preventing any slippage or intraluminal migration. The Marlex mesh bands produced the least amount of complications and were the most popular choice.
Sizing of the bands varied from author to author. Mason looked at three different sizes of the Marlex band—4.5 cm, 5 cm and 5.5 cm. Of the three, the 4.5 cm band had the best five year success in weight loss (defined as loss of more than 25% of the excess weight) but the highest five year reoperative rate (9%). Patients also tended to have stricter dietary restrictions and more difficulty tolerating a regular diet leading to dissatisfaction. Many then began to take in higher calorie drinks and processed food. Ultimately, this dietary change led to weight gain. The 5.0 cm band group did the best overall with over 78% of patients having successful weight loss while only 6.1% required re-operation. Most importantly, these patients tolerated regular food better and were more compliant with the postgastroplasty diets. The 5.5 cm bands had disappointing weight loss results. MacLean used a double layer of
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