Gastric David
restriction
Michael
Gastric
horizontal
erations troplasty,
gastroplasties
were
unsuccessful
but
such as vertical banded gastroplasty, and gastric banding produce good
improvement
in health.
satisfactory
5-y results
trials
treatment
still
ring gasloss with
Obesity,
possible,
(5).
Gastric
Patient
modern
occur,
operations Am J Clin
needed.
with Nuir
The
gastroplasty,
gastric
restriction
is less apt
to dilate
reduced
vertical
than
a hor-
to the smallest
silastic
ring
brief
review
restriction
has
been
physiological procedure some malabsorption.
is
regarded
than
gastric
by proponents
as a
bypass,
pro-
which
selection
Criteria tients
the
attempts
to summarize
the current
status
of
procedures, which are operations designed to weight loss in a simple, safe way. The early
horizontal gastroplasties up. The most common
proved modern
ineffective operation
on long-term is the vertical
followbanded
which is much more effective. Silastic ring gastrogastric banding are other examples ofeffective gastric procedures. Gastric restriction is less effective than
gastric
bypass
simple
and
in achieving
safe than long-term
are presented.
data
Patient
mechanism
weight
gastric
loss
bypass,
from
and
appears
fewer
the literature
and
selection,
of action,
but
with
complications
future
studies
to be more
for patient
should
selection
be between
indication
are reviewed
18 and
50 y,
elsewhere
45 kg above
(6). Pa-
ideal
diet. Reversible medical mellitus, and hypertension
for operation,
ress in predicting weight loss before
as does
results
(9).
weight loss gastroplasty
Sugerman
truncal
weight,
problems increase
obesity.
Team
I have though tivation,
attempted to control weight loss may suffer eating habits, social
teristics
are needed.
that
relieve
predict
used
sweets
intake
to determine
patients may need to achieve satisfactory
obese
operations
loss
as-
and may prog-
been made (8). Mandatory increase safety and improve
Extremely
weight
personal
and
has may
et al (10)
the type ofoperation needed. more risky malabsorptive
complications. series
size
gastroplasty
a comparable procedure (4). Gastric banding is a simple alternative to gastroplasty that avoids the potential problems of staples
studies follow-
does
10- 1 5 mL.
and
sessment is emphasized. Assessment of patient motivation prediction of results has been poor. Psychological factors predict complications better than weight loss (7), but some
gastric-restriction achieve significant
Available
size has been
Patient
gain
Introduction
gastroplasty, plasty and restriction
better
Pouch
and have failed a supervised such as sleep apnea, diabetes
WORDS
This
drains
pouch.
and are presented.
weight
comparing are
silastic weight
op-
pouch
izontal
ofaction, and future with complete patient
late
are available
randomized
modern
1992;55:556S-9S.
KEY
i’2
vertical
more duces
Although
selection, complications, mechanism are also discussed. Long-term data nonoperative
severe
complications
but
data
are still
lacking.
smoking before gastroplasty, al( 1 1).Accurate tests to define mosupport, and personality charac-
successful
and
uncomplicated
weight
loss
of operations,
are
reviewed.
Results Subjects
and methods
Personal
The operations operative deaths
The operations Gastric
restriction
upper
pouch
They
have
by Mason
evolved
divide
horizontal
from
the
bypass
Modern
insert four types ofgastric with
the stomach
connected
gastric
Ito (1) in 1967.
Recent instruments 1 illustrates some were
procedures
and large lower portion
and
data
into
a small
by a small operation
stapling
devices
stoma.
described are used.
parallel rows of staples. Figure restriction. At first staple lines
an opening
in the
middle
including distal
can be done in a personal
17 1 horizontal
gastric
bypasses,
safely. series
gastroplasties, 16 gastric
banding
There have of operations 137 gastric procedures,
been no postfor obesity, bypasses,
26
388 vertical
banded gastroplasties, and 129 revision gastroplasties. Because of simplicity and safety the vertical banded gastroplasty is preferred at our institution but the gastric bypass is still used for some
patients
over
159 kg. Horizontal
gastroplasty
is ineffective,
or at the greater
Early results were good but most operations failed because ofenlargement ofthe gastric fundus or stoma. Erosion of Marlex sutured to the stomach was an additional problem (2). The vercurve.
tical
banded
most common 556S
gastroplasty
described
operation
performed
by
Mason
for obesity.
(3)
is now
The lesser-curve
Am J C/in Nuir
the
I From the Department of Surgery, University of Western Ontario, London, Ontario, Canada. 2 Address reprint requests to DM Grace, University Hospital, 339
Windermere
1992;55:556S-9S.
Printed
Road,
London,
in USA.
Ontario
N6A
© 1992 American
5A5, Canada. Society
for Clinical
Nutrition
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/556S/4715341 by guest on 04 February 2019
restriction procedures are operations volume. They are the most common, simple, for the treatment ofsevere obesity. The orig-
ABSTRACT
up and
for treating
Grace
to decrease gastric and safe operations inal
procedures
GASTRIC
RESTRICTION
FOR
SEVERE
557S
OBESITY
long-term effectiveness of vertical banded gastroplasty because missing patients may be failures. In our patients, additional procedures
performed of the
patients),
sional
hernia
repair
terectomy ruption
was
studies
were
iting GASTROPLASTIES
weight
SILASTtC
RING
GASTROPLASTY
FIG 1 . Examples ofgastric-restriction procedures. The top row shows horizontal gastroplasties that eventually failed. The bottom row shows the operations in current use. They are gastric banding, vertical banded gastroplasty, and vertical ring gastroplasty.
in height
and
One-year
162 cm in height
151 kg in weight
with
weight
a BMI
plasties in our series was 30% of initial 27% for males. Some 92% of patients losing
25%
been
difficult.
This
is partially
served
Health solved. Mood
were fruit, hair
and
body
After
1 y 16%
explained
the
176 cm
of 49.
vertical
banded for females
could
not
and
geographic
in severe
in has
be located. area
winter
that
is
loss.
Of
102 patients
followed
for 5 y after
vertical
banded
72 (7 1%) were
gastroplasty
3.5 y after
gastroplasty
and
available for review. Two had a reone, who had an excellent result, died
from
an
industrial
accident.
Of the
More
complete
follow-up
is necessary
69
Average loss was retained of body
to determine
the
or
barium
for significant
disruptions
were
vom-
likely
missed.
only for severe health obesity or for significant
and gastric
difficult
National
bypass operations Of S 178 operations Association in Iowa
to obtain.
Bariatric
Surgery
unpublished
The most common banded gastroplasty
Late
(13.3%)
and
resultsfrom
Late widely.
observation,
1991),
64%
were
The
are
Mason
group
gastric
of ideal
weight)
patients
who of 537 follow-up
banding
by silastic
was
ring gas-
(6.4%).
available
after
gastroplasty
The
with
0.25%
were
163 morbidly
obese
three
225%
weight)
or 50 kg. Yale(l3)
and
who
in an unrandomized
operations
He defined
patients(
225%
with
and 5 was not stated.
or 35 kg, and 93
super
of94.2%.
differ
weight
weight
patients
they
mortality
lost to follow-up
number into
but
on an 8-y experience
who lost 62% ofexcess
lost 53% ofexcess term
procedure
followed
et al (12) reported banded gastroplasties
was divided
study
gastric-restriction
(78%)
the literature
results
1200 vertical y follow-up on 256.
succeeded
failure
as weight
in longloss
25% after 5 y while 78% had lost > 10% weight.
gastro-
seen were successful but complete follow-up
large
of driving
average
weight
of patients
by the
difficulty
125 kg in weight
problems such as diabetes mellitus and hypertension reMenstrual periods returned and became more regular. and exercise tolerance improved. The major complaints vomiting, especially with solid food such as meat, fresh and vegetables; constipation; cold intolerance; and minor
gastroplasty,
vision
weight,
ofinitial
and
and males
loss for the first 200
gastroscopy
and 36% gastric restriction with malabsorption (gastric bypass). However, there has been a recent decrease in the proportion of gastric-restriction procedures. In 1987, 70% of reported operations were gastric restriction and 30% gastric bypass. By 1989 gastric restriction was 58% and gastric bypass 42% of reported operations. The reasons for this trend are not clear but may be related to better weight loss achieved by gastric
troplasty
there are a few lO-y successes. Gastric banding in our has an unacceptable rate ofstoma obstruction, while gastric bypass is effective but more difficult than gastroplasty and has potential complications such as acute gastric dilatation. Long-term follow-up is important after all operations for obesity but especially after gastric bypass because oflate problems such as iron or vitamin B-l2 deficiency and osteomalacia. The typical patient population is 85% female and 15% male and mean age
perdis-
restriction
bypass. vertical
although experience
hys-
was
3 1%. In spite
gastroplasty
because
of the
higher
ofsimplicity
and
failure safety.
rate, The
he preAdelaide
group (14) carried out a randomized trial of three operations for obesity. Follow-up at 3 y was 91%. Success was defined as loss
of
>
50%
of excess
weight
or current
pregnancy.
Success
was 17% for gastrogastrostomy, 48% for vertical gastroplasty, and 67% for gastric bypass, and gastric bypass was recommended. Probably
the
most
plasty was carried He used a smaller 14.5% 2%)
of200 was
patients
rigorous
study
of vertical
banded
gastro-
out by MacLean et al (15) on 201 patients. stoma than described by Mason (3). He lost to follow-up
after
2 y but
only
1 of57
(or
after 5 y. Reaching a goal weight within was a good result. Weight loss > 25% was satisfac-
unavailable
30% of ideal tory. He was able to achieve good or satisfactory results in 7580% ofpatients in each ofthe 5 postoperative years but 73(36%) of patients required a total of 82 reoperations. Weight loss was 3 1% at 1 y and 33.8% at 5 y. Patients were seen frequently and had regular gastroscopy. A very high 48% rate of staple line
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/556S/4715341 by guest on 04 February 2019
BANDED
GASTROPLASVY
are
to The
in 4 (6%),
in 2 (3%), and in 1. Staple-line
needed
for gastroplasty
(K Renquist,
gastric
of48,
some
19
mci-
cholecystectomy
but
(in
in 10 (14%),
America
America
reported
(BMI)
loss and
numbers
by 1989
is 36 y. Females average mass index
in S (7%),
in North
Exact
with a body
28 gastroscopies
lipectomy
Revision gastroplasty was performed problems due to persistent or recurrent stoma obstruction.
in North
VERTICAL
5 y included
identified in 8 (12%) carried out only when
or poor
Operations
GASTRIC BAND$NG
the
abdominal
in 4 (6%), revision gastroplasties postoperative abscess drainage
cutaneous
HORIZONTAL
over
(28%)
GRACE
558S disruption
was
found,
although
not
Some disruptions were detected plasty. Mason (16) reported a 0.9% 3 y after
gastroplasty.
The
all required 5 y after the
reoperation. initial gastro-
rate of partition
breakdown
results
be due
contrasting
completeness ofinvestigation and different et al ( 15) used a stoma below recommended
could
Dr EE Mason (3) deserves credit for devising the operation and for his continuing work in the field. The operation is safe and easy, maintains normal digestion and absorption, and proplasty.
to
technique. MacLean size and stapling
prevented
techniques and instruments may have differed. He now raeommends dividing between staple lines, which would decrease weight gain due to staple disruption but might increase postoperative leaks and peritonitis. A randomized trial may be needed to answer the question. MacLean et al (15) also had a rate
of obstruction,
probably
has set a high standard loss after gastroplasty. the quality
oflife,
due
to the
stoma.
He
follow-up and for good weight we need more information on of vomiting, and ability to eat nor-
frequency
mal food. His patients did maintain a normal in spite ofdramatic weight loss (17). Research determine the degree of weight loss required to No attempt has been made to analyze the gastric-restriction may give slightly
small
for patient However,
procedures better results
nutritional
state
is still needed to improve health. results of other ring gastroplasty
in detail. Vertical than vertical banded
gastroplasty
(18), and the procedure is quite simple, but late data are needed. Erosion of a band sutured to rather than around the stomach is a potential late problem. Gastric banding is a simple concept but in our experience and in reported studies has a high complication rate (19, 20). Kuzmak (5)developed an inflatable gastric band that may have some advantages, but late results are needed.
Complications
shown
by our
gastroplasties gastric
tively,
and
leaks
troplasty monary
series with
and both problems chest
with
867
by Dr Mason elsewhere mortality can be low
no deaths
operations
abdominal
after for
abscess
388
obesity. after
vertical I have
vertical
in as
banded seen two
banded
gas-
were treated by percutaneous drainage. Pulare low with control of smoking preopera-
physiotherapy,
and
early
mobilization.
Failure
to
lose weight or late weight gain are often due to technical factors but motivation is important. Severe complications can occur after vertical banded gastroplasty (22). I have managed 16 patients
from
other
centers
with
problems
ranging
from
complete
stoma obstruction abdominal sepsis should be carried
with malnutrition to severe and prolonged with external gastric fistula. These operations out in centers with an adequate volume of
patients to develop multidisciplinary
and maintain care is available
expertise when
and in hospitals where complications occur. I
have
seen six late deaths from 1.5 to 4 y after gastroplasty and gastric bypass procedures. The causes were industrial accident, murder (by jealous boyfriend), stroke, heart attack, small bowel obstruction, and asthmatic attack. No attempt is made here to analyze the many health benefits of dramatic weight loss or the emotional improvement as formerly obese patients lose weight. The gratitude ofthese patients is a major factor in our continuing work with obese individuals.
intake
of high-calorie
created
Vertical banded gastroplasty ation for the treatment ofsevere
is a much more effective operobesity than horizontal gastro-
soft
discourage
thetic
regular
materials
around
empties Stoma
well and dilatation
can is
but the small
stoma
does
and
vegetables
and
encourages
foods.
The
tiny
pouches
now
meals
and encourage
snacking.
Pros-
can
staple
intake
a stoma
gastric
erode
and
dis-
lines
can
disrupt resulting in weight gain. There is no doubt that health problems improve as weight is lost and that early weight loss is good with vertical banded gastroplasty. Our own data in a small number ofpatients show the problems that occur with late weight gain and in achieving cornplete follow-up data on all patients. Results may improve with time as a result of operative experience, smaller pouches, more secure stapling devices, and better patient selection. MacLean ( 1 5) used a smaller stoma than generally
mended, he showed that excellent over 5 y with an intact gastroplasty. outstanding. The high proportion
ofstaple
in his series
be related
is disturbing
and
weight
loss can be achieved
His degree
may
Although recom-
of follow-up
was
line disruptions
seen
to the small
stoma
and stapling techniques, but no one else has carried out such thorough postoperative investigation. A high rate of revision operations may be necessary to achieve such results but revision operations
carry
more
risk
weight
loss. One awaits
in his
analysis
Decreased
ofthe
primary
loss
and
in a very large
caloric
adaptation
than
with interest
of weight
gastroplasty
intake
diet
mortality
even
after
data of Mason rate
series
explains
is critical
operations,
the complete
after
vertical
loss
whereas
of patients.
early
weight
to long-term
success.
Decreasing
stoma size encourages intake of high-calorie fluids. Snack foods such as cookies and potato chips are easily eaten, although binging is difficult. In spite of careful instruction and close followup, patient compliance with dietary instruction may be poor (23).
Patient
is no clear
motivation relationship
may
be a critical
between
weight
factor
loss and
because stoma
there
diameter
or pouch volume (24). However, MacLean (15) feel that technical problems such as staple disruption explain most poor results. At one time delayed pouch emptying was thought to be important in weight loss, but emptying is more rapid after vertical banded than horizontal gastroplasty yet weight loss is better (25). Low pouch volume may be important but very small pouches may encourage technical problems and esophageal dilatation. Good technique appears to be much more critical for successful gastroplasty
standing
than
ofsatiety
for
successful
gastric
and adaptation
bypass.
measures
Better
after
under-
gastroplasty
is
needed.
The gastroplasty operations can be carried out safely in severely obese people with good early weight loss. Better data are needed on the long-term effectiveness of these operations. Quality of life resulting from dietary changes, weight loss, and sometimes weight regain needs to be assessed. Health and survival benefits from weight loss must also be assessed. Total costs must be determined for the operations and supportive care and for investigation and treatment required as a result ofweight loss or cornplications.
Discussion
gastric pouch or endoscopy.
by the encircling band ofmeat, fresh fruit,
courage
banded
These are reviewed in more detail this supplement (2 1). Postoperative
loss. The by x ray
by weight
loss
and the economic impact of return to the work force must be considered. The Swedish Obesity Subjects (SOS) trial
also (26)
presently
The
decrease
underway
in medical
will assess
costs
achieved
the effectiveness
ofgastric
banding
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/556S/4715341 by guest on 04 February 2019
high
duces good weight be easily assessed
GASTRIC and
vertical
mortality
banded of severely
gastroplasty obese
in decreasing
patients
RESTRICTION morbidity
in comparison
nomic
status.
Better
nonoperative
treat the epidemic ofobesity the rest of the developed
methods that world.
region,
even
as socioeco-
are needed
is sweeping
and
to matched
controls. However, results may vary with geographic within North America, and with other factors such and and
FOR
North
to prevent America
U
References
OBESITY
559S
1 1. Grace DM, Pederson L, Speechley KN, McAlpine D. A longitudinal study of smoking status and weight loss following gastroplasty in a group of morbidly obese patients. Int J Obes 1990; 14:3 1 1-7. 12. Mason EE, Doherty C, Scott DH, MaherJW, Rodriguez EM. Vertical banded gastroplasty (VBG) for treatment ofobesity: an eighth year review. mt J Obes l989;l3:593(abstr). 13. Yale CE. Gastric surgery for morbid obesity: complications and longterm weight control. Arch Surg l989;l24:94l-6. 14. Hall JC, Watts JM, O’Brien PE, et al. Gastric surgery for morbid obesity. The Adelaide study. Ann Surg 1990;21 1:419-27. 15. MacLean LD, Rhode BM, Forse RA. Late results ofvertical banded gastroplasty for morbid and super obesity. Surgery I990;107:20-7. 16. Mason EE. Morbid obesity: use ofvertical banded gastroplasty. Surg Clin North Am l987;67:52l-9. 17. MacLean LD, Rhode B, Shizgal HM. Nutrition after vertical banded gastroplasty. Ann Surg l987;206:555-63. 18. Willbanks OL. Long term results ofsilicone elastomer ring vertical gastroplasty for the treatment of morbid obesity. Surgery 1987;l0l: 606- 10. 19. Granstrom L, Backman L. Technical complications and related operations after gastric banding. Acta Chir Scand 1987; 153:215-20. 20. Kirby RM, Ismail I, Crowson M, Baddeley RM. Gastric banding in the treatment of morbid obesity. Br J Surg l989;76:490-2. 21. Mason EE, Renquist KE, Jiang D. Perioperative risks and safety of surgery for severe obesity. Am J Clin Nutr 1992;55(suppl):573S6S. 22. Buckwalter JA, Herbst CA. Leak after vertical banded gastroplasty. South Med J l989;82:525-6. 23. Andersen I, Larsen U. Dietary outcome in obese patients treated with a gastroplasty program. Am J Clin Nutr 1989;50:l328-40. 24. Behrns KE, Soper NJ, Sarr MG, Kelly KA, Hughes RW. Anatomic, motor and clinical assessment of vertical banded gastroplasty. Gastroenterology l989;97:9l-7. 25. Andersen I, Pederson BH, Dissing I, Astrup A, Henriksen JH. A randomized comparison of horizontal and vertical banded gastroplasty: what determines weight loss. Scand J Gastroenterol l989;24: 186-92. 26. Sjostrom L, Backman L, Bengtsson C, et al. Announcement of the multicentre project “Swedish Obesity Subjects”-SOS. Int J Obes 1987; 1 1:87(abstr).
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1. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am l967;47: 1345-52. 2. Grace DM. Recognition and management of Marlex erosion after horizontal gastroplasty for morbid obesity. Can J Surg l987;30: 282-5. 3. Mason EE. Vertical banded gastroplasty for obesity. Arch Surg l982;l 17:701-6. 4. Eckhout GV, Willbanks OL, Moore JT. Vertical ring gastroplasty for obesity: five year experience with 1463 patients. Am J Surg 1986;l52:7l3-6. 5. Kuzmak LI. Gastric banding. In: Deitel M, ed. Surgery for the morbidly obese patient. Philadelphia: Lea and Febiger, 1989:225-59. 6. Grace DM. Patient selection for obesity surgery. Gastroenterol Clin North Am 1987;l6:399-4l3. 7. Valley V, Grace DM. Psychosocial risk factors in gastric surgery for obesity: identifying guidelines for screening. Int J Obes 1987;l 1: 105- 13. 8. Barrash J, Rodriguez EM, Scott DM, Mason EE, Sines JO. The utility of MMPI subtypes for the prediction ofweight loss after bariatric surgery. Int J Obes 1987;l 1:115-128. 9. Andersen T, Backer DO, Astrup A, Quaade F. Horizontal or vertical banded gastroplasty after pretreatment with very-low-calorie formula diet: a randomized trial. Int J Obes 1987;l 1:295-304. 10. Sugerman HJ, Starkey JV, Birkenhauer R. A randomized prospective trial ofgastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters. Ann Surg 1987;205:6 13-24.
SEVERE
restriction
Michael
Gastric
horizontal
erations troplasty,
gastroplasties
were
unsuccessful
but
such as vertical banded gastroplasty, and gastric banding produce good
improvement
in health.
satisfactory
5-y results
trials
treatment
still
ring gasloss with
Obesity,
possible,
(5).
Gastric
Patient
modern
occur,
operations Am J Clin
needed.
with Nuir
The
gastroplasty,
gastric
restriction
is less apt
to dilate
reduced
vertical
than
a hor-
to the smallest
silastic
ring
brief
review
restriction
has
been
physiological procedure some malabsorption.
is
regarded
than
gastric
by proponents
as a
bypass,
pro-
which
selection
Criteria tients
the
attempts
to summarize
the current
status
of
procedures, which are operations designed to weight loss in a simple, safe way. The early
horizontal gastroplasties up. The most common
proved modern
ineffective operation
on long-term is the vertical
followbanded
which is much more effective. Silastic ring gastrogastric banding are other examples ofeffective gastric procedures. Gastric restriction is less effective than
gastric
bypass
simple
and
in achieving
safe than long-term
are presented.
data
Patient
mechanism
weight
gastric
loss
bypass,
from
and
appears
fewer
the literature
and
selection,
of action,
but
with
complications
future
studies
to be more
for patient
should
selection
be between
indication
are reviewed
18 and
50 y,
elsewhere
45 kg above
(6). Pa-
ideal
diet. Reversible medical mellitus, and hypertension
for operation,
ress in predicting weight loss before
as does
results
(9).
weight loss gastroplasty
Sugerman
truncal
weight,
problems increase
obesity.
Team
I have though tivation,
attempted to control weight loss may suffer eating habits, social
teristics
are needed.
that
relieve
predict
used
sweets
intake
to determine
patients may need to achieve satisfactory
obese
operations
loss
as-
and may prog-
been made (8). Mandatory increase safety and improve
Extremely
weight
personal
and
has may
et al (10)
the type ofoperation needed. more risky malabsorptive
complications. series
size
gastroplasty
a comparable procedure (4). Gastric banding is a simple alternative to gastroplasty that avoids the potential problems of staples
studies follow-
does
10- 1 5 mL.
and
sessment is emphasized. Assessment of patient motivation prediction of results has been poor. Psychological factors predict complications better than weight loss (7), but some
gastric-restriction achieve significant
Available
size has been
Patient
gain
Introduction
gastroplasty, plasty and restriction
better
Pouch
and have failed a supervised such as sleep apnea, diabetes
WORDS
This
drains
pouch.
and are presented.
weight
comparing are
silastic weight
op-
pouch
izontal
ofaction, and future with complete patient
late
are available
randomized
modern
1992;55:556S-9S.
KEY
i’2
vertical
more duces
Although
selection, complications, mechanism are also discussed. Long-term data nonoperative
severe
complications
but
data
are still
lacking.
smoking before gastroplasty, al( 1 1).Accurate tests to define mosupport, and personality charac-
successful
and
uncomplicated
weight
loss
of operations,
are
reviewed.
Results Subjects
and methods
Personal
The operations operative deaths
The operations Gastric
restriction
upper
pouch
They
have
by Mason
evolved
divide
horizontal
from
the
bypass
Modern
insert four types ofgastric with
the stomach
connected
gastric
Ito (1) in 1967.
Recent instruments 1 illustrates some were
procedures
and large lower portion
and
data
into
a small
by a small operation
stapling
devices
stoma.
described are used.
parallel rows of staples. Figure restriction. At first staple lines
an opening
in the
middle
including distal
can be done in a personal
17 1 horizontal
gastric
bypasses,
safely. series
gastroplasties, 16 gastric
banding
There have of operations 137 gastric procedures,
been no postfor obesity, bypasses,
26
388 vertical
banded gastroplasties, and 129 revision gastroplasties. Because of simplicity and safety the vertical banded gastroplasty is preferred at our institution but the gastric bypass is still used for some
patients
over
159 kg. Horizontal
gastroplasty
is ineffective,
or at the greater
Early results were good but most operations failed because ofenlargement ofthe gastric fundus or stoma. Erosion of Marlex sutured to the stomach was an additional problem (2). The vercurve.
tical
banded
most common 556S
gastroplasty
described
operation
performed
by
Mason
for obesity.
(3)
is now
The lesser-curve
Am J C/in Nuir
the
I From the Department of Surgery, University of Western Ontario, London, Ontario, Canada. 2 Address reprint requests to DM Grace, University Hospital, 339
Windermere
1992;55:556S-9S.
Printed
Road,
London,
in USA.
Ontario
N6A
© 1992 American
5A5, Canada. Society
for Clinical
Nutrition
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/556S/4715341 by guest on 04 February 2019
restriction procedures are operations volume. They are the most common, simple, for the treatment ofsevere obesity. The orig-
ABSTRACT
up and
for treating
Grace
to decrease gastric and safe operations inal
procedures
GASTRIC
RESTRICTION
FOR
SEVERE
557S
OBESITY
long-term effectiveness of vertical banded gastroplasty because missing patients may be failures. In our patients, additional procedures
performed of the
patients),
sional
hernia
repair
terectomy ruption
was
studies
were
iting GASTROPLASTIES
weight
SILASTtC
RING
GASTROPLASTY
FIG 1 . Examples ofgastric-restriction procedures. The top row shows horizontal gastroplasties that eventually failed. The bottom row shows the operations in current use. They are gastric banding, vertical banded gastroplasty, and vertical ring gastroplasty.
in height
and
One-year
162 cm in height
151 kg in weight
with
weight
a BMI
plasties in our series was 30% of initial 27% for males. Some 92% of patients losing
25%
been
difficult.
This
is partially
served
Health solved. Mood
were fruit, hair
and
body
After
1 y 16%
explained
the
176 cm
of 49.
vertical
banded for females
could
not
and
geographic
in severe
in has
be located. area
winter
that
is
loss.
Of
102 patients
followed
for 5 y after
vertical
banded
72 (7 1%) were
gastroplasty
3.5 y after
gastroplasty
and
available for review. Two had a reone, who had an excellent result, died
from
an
industrial
accident.
Of the
More
complete
follow-up
is necessary
69
Average loss was retained of body
to determine
the
or
barium
for significant
disruptions
were
vom-
likely
missed.
only for severe health obesity or for significant
and gastric
difficult
National
bypass operations Of S 178 operations Association in Iowa
to obtain.
Bariatric
Surgery
unpublished
The most common banded gastroplasty
Late
(13.3%)
and
resultsfrom
Late widely.
observation,
1991),
64%
were
The
are
Mason
group
gastric
of ideal
weight)
patients
who of 537 follow-up
banding
by silastic
was
ring gas-
(6.4%).
available
after
gastroplasty
The
with
0.25%
were
163 morbidly
obese
three
225%
weight)
or 50 kg. Yale(l3)
and
who
in an unrandomized
operations
He defined
patients(
225%
with
and 5 was not stated.
or 35 kg, and 93
super
of94.2%.
differ
weight
weight
patients
they
mortality
lost to follow-up
number into
but
on an 8-y experience
who lost 62% ofexcess
lost 53% ofexcess term
procedure
followed
et al (12) reported banded gastroplasties
was divided
study
gastric-restriction
(78%)
the literature
results
1200 vertical y follow-up on 256.
succeeded
failure
as weight
in longloss
25% after 5 y while 78% had lost > 10% weight.
gastro-
seen were successful but complete follow-up
large
of driving
average
weight
of patients
by the
difficulty
125 kg in weight
problems such as diabetes mellitus and hypertension reMenstrual periods returned and became more regular. and exercise tolerance improved. The major complaints vomiting, especially with solid food such as meat, fresh and vegetables; constipation; cold intolerance; and minor
gastroplasty,
vision
weight,
ofinitial
and
and males
loss for the first 200
gastroscopy
and 36% gastric restriction with malabsorption (gastric bypass). However, there has been a recent decrease in the proportion of gastric-restriction procedures. In 1987, 70% of reported operations were gastric restriction and 30% gastric bypass. By 1989 gastric restriction was 58% and gastric bypass 42% of reported operations. The reasons for this trend are not clear but may be related to better weight loss achieved by gastric
troplasty
there are a few lO-y successes. Gastric banding in our has an unacceptable rate ofstoma obstruction, while gastric bypass is effective but more difficult than gastroplasty and has potential complications such as acute gastric dilatation. Long-term follow-up is important after all operations for obesity but especially after gastric bypass because oflate problems such as iron or vitamin B-l2 deficiency and osteomalacia. The typical patient population is 85% female and 15% male and mean age
perdis-
restriction
bypass. vertical
although experience
hys-
was
3 1%. In spite
gastroplasty
because
of the
higher
ofsimplicity
and
failure safety.
rate, The
he preAdelaide
group (14) carried out a randomized trial of three operations for obesity. Follow-up at 3 y was 91%. Success was defined as loss
of
>
50%
of excess
weight
or current
pregnancy.
Success
was 17% for gastrogastrostomy, 48% for vertical gastroplasty, and 67% for gastric bypass, and gastric bypass was recommended. Probably
the
most
plasty was carried He used a smaller 14.5% 2%)
of200 was
patients
rigorous
study
of vertical
banded
gastro-
out by MacLean et al (15) on 201 patients. stoma than described by Mason (3). He lost to follow-up
after
2 y but
only
1 of57
(or
after 5 y. Reaching a goal weight within was a good result. Weight loss > 25% was satisfac-
unavailable
30% of ideal tory. He was able to achieve good or satisfactory results in 7580% ofpatients in each ofthe 5 postoperative years but 73(36%) of patients required a total of 82 reoperations. Weight loss was 3 1% at 1 y and 33.8% at 5 y. Patients were seen frequently and had regular gastroscopy. A very high 48% rate of staple line
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/556S/4715341 by guest on 04 February 2019
BANDED
GASTROPLASVY
are
to The
in 4 (6%),
in 2 (3%), and in 1. Staple-line
needed
for gastroplasty
(K Renquist,
gastric
of48,
some
19
mci-
cholecystectomy
but
(in
in 10 (14%),
America
America
reported
(BMI)
loss and
numbers
by 1989
is 36 y. Females average mass index
in S (7%),
in North
Exact
with a body
28 gastroscopies
lipectomy
Revision gastroplasty was performed problems due to persistent or recurrent stoma obstruction.
in North
VERTICAL
5 y included
identified in 8 (12%) carried out only when
or poor
Operations
GASTRIC BAND$NG
the
abdominal
in 4 (6%), revision gastroplasties postoperative abscess drainage
cutaneous
HORIZONTAL
over
(28%)
GRACE
558S disruption
was
found,
although
not
Some disruptions were detected plasty. Mason (16) reported a 0.9% 3 y after
gastroplasty.
The
all required 5 y after the
reoperation. initial gastro-
rate of partition
breakdown
results
be due
contrasting
completeness ofinvestigation and different et al ( 15) used a stoma below recommended
could
Dr EE Mason (3) deserves credit for devising the operation and for his continuing work in the field. The operation is safe and easy, maintains normal digestion and absorption, and proplasty.
to
technique. MacLean size and stapling
prevented
techniques and instruments may have differed. He now raeommends dividing between staple lines, which would decrease weight gain due to staple disruption but might increase postoperative leaks and peritonitis. A randomized trial may be needed to answer the question. MacLean et al (15) also had a rate
of obstruction,
probably
has set a high standard loss after gastroplasty. the quality
oflife,
due
to the
stoma.
He
follow-up and for good weight we need more information on of vomiting, and ability to eat nor-
frequency
mal food. His patients did maintain a normal in spite ofdramatic weight loss (17). Research determine the degree of weight loss required to No attempt has been made to analyze the gastric-restriction may give slightly
small
for patient However,
procedures better results
nutritional
state
is still needed to improve health. results of other ring gastroplasty
in detail. Vertical than vertical banded
gastroplasty
(18), and the procedure is quite simple, but late data are needed. Erosion of a band sutured to rather than around the stomach is a potential late problem. Gastric banding is a simple concept but in our experience and in reported studies has a high complication rate (19, 20). Kuzmak (5)developed an inflatable gastric band that may have some advantages, but late results are needed.
Complications
shown
by our
gastroplasties gastric
tively,
and
leaks
troplasty monary
series with
and both problems chest
with
867
by Dr Mason elsewhere mortality can be low
no deaths
operations
abdominal
after for
abscess
388
obesity. after
vertical I have
vertical
in as
banded seen two
banded
gas-
were treated by percutaneous drainage. Pulare low with control of smoking preopera-
physiotherapy,
and
early
mobilization.
Failure
to
lose weight or late weight gain are often due to technical factors but motivation is important. Severe complications can occur after vertical banded gastroplasty (22). I have managed 16 patients
from
other
centers
with
problems
ranging
from
complete
stoma obstruction abdominal sepsis should be carried
with malnutrition to severe and prolonged with external gastric fistula. These operations out in centers with an adequate volume of
patients to develop multidisciplinary
and maintain care is available
expertise when
and in hospitals where complications occur. I
have
seen six late deaths from 1.5 to 4 y after gastroplasty and gastric bypass procedures. The causes were industrial accident, murder (by jealous boyfriend), stroke, heart attack, small bowel obstruction, and asthmatic attack. No attempt is made here to analyze the many health benefits of dramatic weight loss or the emotional improvement as formerly obese patients lose weight. The gratitude ofthese patients is a major factor in our continuing work with obese individuals.
intake
of high-calorie
created
Vertical banded gastroplasty ation for the treatment ofsevere
is a much more effective operobesity than horizontal gastro-
soft
discourage
thetic
regular
materials
around
empties Stoma
well and dilatation
can is
but the small
stoma
does
and
vegetables
and
encourages
foods.
The
tiny
pouches
now
meals
and encourage
snacking.
Pros-
can
staple
intake
a stoma
gastric
erode
and
dis-
lines
can
disrupt resulting in weight gain. There is no doubt that health problems improve as weight is lost and that early weight loss is good with vertical banded gastroplasty. Our own data in a small number ofpatients show the problems that occur with late weight gain and in achieving cornplete follow-up data on all patients. Results may improve with time as a result of operative experience, smaller pouches, more secure stapling devices, and better patient selection. MacLean ( 1 5) used a smaller stoma than generally
mended, he showed that excellent over 5 y with an intact gastroplasty. outstanding. The high proportion
ofstaple
in his series
be related
is disturbing
and
weight
loss can be achieved
His degree
may
Although recom-
of follow-up
was
line disruptions
seen
to the small
stoma
and stapling techniques, but no one else has carried out such thorough postoperative investigation. A high rate of revision operations may be necessary to achieve such results but revision operations
carry
more
risk
weight
loss. One awaits
in his
analysis
Decreased
ofthe
primary
loss
and
in a very large
caloric
adaptation
than
with interest
of weight
gastroplasty
intake
diet
mortality
even
after
data of Mason rate
series
explains
is critical
operations,
the complete
after
vertical
loss
whereas
of patients.
early
weight
to long-term
success.
Decreasing
stoma size encourages intake of high-calorie fluids. Snack foods such as cookies and potato chips are easily eaten, although binging is difficult. In spite of careful instruction and close followup, patient compliance with dietary instruction may be poor (23).
Patient
is no clear
motivation relationship
may
be a critical
between
weight
factor
loss and
because stoma
there
diameter
or pouch volume (24). However, MacLean (15) feel that technical problems such as staple disruption explain most poor results. At one time delayed pouch emptying was thought to be important in weight loss, but emptying is more rapid after vertical banded than horizontal gastroplasty yet weight loss is better (25). Low pouch volume may be important but very small pouches may encourage technical problems and esophageal dilatation. Good technique appears to be much more critical for successful gastroplasty
standing
than
ofsatiety
for
successful
gastric
and adaptation
bypass.
measures
Better
after
under-
gastroplasty
is
needed.
The gastroplasty operations can be carried out safely in severely obese people with good early weight loss. Better data are needed on the long-term effectiveness of these operations. Quality of life resulting from dietary changes, weight loss, and sometimes weight regain needs to be assessed. Health and survival benefits from weight loss must also be assessed. Total costs must be determined for the operations and supportive care and for investigation and treatment required as a result ofweight loss or cornplications.
Discussion
gastric pouch or endoscopy.
by the encircling band ofmeat, fresh fruit,
courage
banded
These are reviewed in more detail this supplement (2 1). Postoperative
loss. The by x ray
by weight
loss
and the economic impact of return to the work force must be considered. The Swedish Obesity Subjects (SOS) trial
also (26)
presently
The
decrease
underway
in medical
will assess
costs
achieved
the effectiveness
ofgastric
banding
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/556S/4715341 by guest on 04 February 2019
high
duces good weight be easily assessed
GASTRIC and
vertical
mortality
banded of severely
gastroplasty obese
in decreasing
patients
RESTRICTION morbidity
in comparison
nomic
status.
Better
nonoperative
treat the epidemic ofobesity the rest of the developed
methods that world.
region,
even
as socioeco-
are needed
is sweeping
and
to matched
controls. However, results may vary with geographic within North America, and with other factors such and and
FOR
North
to prevent America
U
References
OBESITY
559S
1 1. Grace DM, Pederson L, Speechley KN, McAlpine D. A longitudinal study of smoking status and weight loss following gastroplasty in a group of morbidly obese patients. Int J Obes 1990; 14:3 1 1-7. 12. Mason EE, Doherty C, Scott DH, MaherJW, Rodriguez EM. Vertical banded gastroplasty (VBG) for treatment ofobesity: an eighth year review. mt J Obes l989;l3:593(abstr). 13. Yale CE. Gastric surgery for morbid obesity: complications and longterm weight control. Arch Surg l989;l24:94l-6. 14. Hall JC, Watts JM, O’Brien PE, et al. Gastric surgery for morbid obesity. The Adelaide study. Ann Surg 1990;21 1:419-27. 15. MacLean LD, Rhode BM, Forse RA. Late results ofvertical banded gastroplasty for morbid and super obesity. Surgery I990;107:20-7. 16. Mason EE. Morbid obesity: use ofvertical banded gastroplasty. Surg Clin North Am l987;67:52l-9. 17. MacLean LD, Rhode B, Shizgal HM. Nutrition after vertical banded gastroplasty. Ann Surg l987;206:555-63. 18. Willbanks OL. Long term results ofsilicone elastomer ring vertical gastroplasty for the treatment of morbid obesity. Surgery 1987;l0l: 606- 10. 19. Granstrom L, Backman L. Technical complications and related operations after gastric banding. Acta Chir Scand 1987; 153:215-20. 20. Kirby RM, Ismail I, Crowson M, Baddeley RM. Gastric banding in the treatment of morbid obesity. Br J Surg l989;76:490-2. 21. Mason EE, Renquist KE, Jiang D. Perioperative risks and safety of surgery for severe obesity. Am J Clin Nutr 1992;55(suppl):573S6S. 22. Buckwalter JA, Herbst CA. Leak after vertical banded gastroplasty. South Med J l989;82:525-6. 23. Andersen I, Larsen U. Dietary outcome in obese patients treated with a gastroplasty program. Am J Clin Nutr 1989;50:l328-40. 24. Behrns KE, Soper NJ, Sarr MG, Kelly KA, Hughes RW. Anatomic, motor and clinical assessment of vertical banded gastroplasty. Gastroenterology l989;97:9l-7. 25. Andersen I, Pederson BH, Dissing I, Astrup A, Henriksen JH. A randomized comparison of horizontal and vertical banded gastroplasty: what determines weight loss. Scand J Gastroenterol l989;24: 186-92. 26. Sjostrom L, Backman L, Bengtsson C, et al. Announcement of the multicentre project “Swedish Obesity Subjects”-SOS. Int J Obes 1987; 1 1:87(abstr).
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SEVERE
