Vertical banded gastroplasty, or VBG, is an elective surgical procedure in which the stomach is partitioned with staples and fitted with a plastic band to limit the amount of food that the stomach can hold at one time. Gastroplasty is a term that comes from two Greek words, gaster or "stomach," and plassein , "to form or shape." "Stomach stapling," also known as VBG, is part of a relatively new surgical subspecialty called bariatric surgery. The word "bariatric" is also derived from two Greek words, barys , which means "heavy," and iatros , which means "healer." A restrictive bariatric procedure, VBG controls the amount of food that the stomach can hold—in contrast to malabsorptive surgeries, in which the food is rerouted within the digestive tract to prevent complete absorption of the nutrients in the food.
The purpose of VBG is the treatment of morbid (unhealthy) obesity. It is one of the first successful procedures in bariatric surgery. VBG was developed in its present form in 1982 by Dr. Edward E. Mason, a professor of surgery at the University of Iowa.
Bariatric surgery in general is important in the management of severe obesity because it is the only one as of 2003 that has demonstrated long-term success in the majority of patients. Weight reduction diets, exercise programs, and appetite suppressant medications have had a very low long-term success rate in managing morbid obesity. Most people who try to lose weight on reduced-calorie diets regain two-thirds of the weight lost within one year; within five years, they have gained more weight in addition to all the weight they had lost previously. Appetite suppressants often have undesirable or harmful side effects as well as having a low rate of long-term effectiveness; in 1997 the Food and Drug Administration (FDA) banned the sale of fenfluramine and phentermine ("fen-phen") when they were discovered to cause damage to heart valves.
Obesity is a major health problem not only because it is widespread in the American population—as of 2003, 33% of adults in the United States meet the National Institutes of Health (NIH) criteria for obesity—but because it greatly increases a person's risk of developing potentially life-threatening disorders. Obesity is associated with type 2 (non-insulin-dependent) diabetes, hypertension, abnormal blood cholesterol levels, liver disease, coronary artery disease, sleep apnea syndrome, and certain types of cancer. In addition to these disorders, obesity is a factor in what have been called lifestyle-limiting conditions. These conditions are not life-threatening, but they can have a great impact on a people's day-to-day lives, particularly in their relationships and in the working world. Lifestyle-limiting conditions related to obesity include osteoarthritis and gout; urinary stress incontinence; heartburn; skin disorders caused by heavy perspiration accumulating in folds of skin; leg swelling and varicose veins; gallstones; and abdominal hernias. Obese women frequently suffer from irregular menstrual periods and infertility. Finally, societal prejudice against obese people is widespread and frequently mentioned as a source of acute psychological distress. Surgical treatment of obesity has been demonstrated to relieve emotional pain as well as to reduce risks to the patient's physical health.
Like other procedures in bariatric surgery, VBG is performed only on patients who are severely or morbidly obese by NIH standards. Severe obesity is presently defined as a body mass index (BMI) of 35 or higher. Nonetheless, it is the epidemic with the greatest prevalence in the United States as of 2003. One out of every 20 adults, or 15 million people, have a BMI greater than 35.
At present, few figures are available regarding the number of VBGs performed in the United States each year compared with other types of obesity surgery. The International Bariatric Surgery Registry (IBSR) at the University of Iowa is presently compiling a database to monitor the outcomes of different procedures and to analyze statistical data about patients undergoing obesity surgery. In 2000, the IBSR analyzed data on a group of 14,641 people who had had obesity surgery as of 1998. The patients weighed an average of 280 lb (127 kg) at the time of surgery and had an average BMI of 46. Slightly less than 20% of the patients had BMIs between 35 and 39.9; 76.1% had BMIs of 40 or higher.
There are two major types of VBG—open, which is the older of the two procedures; and the laparoscopic VBG, which is performed through very small incisions, with the help of special instruments.
The open VBG is done under general anesthesia. In most cases, it takes one to two hours to perform. The surgeon makes an incision several inches long in the patient's upper abdomen. After cutting through the layers of tissue over the stomach, the surgeon cuts a hole or "window" into the upper part of the stomach a few inches below the esophagus. The second step involves placing a line of surgical staples from the window in the direction of the esophagus, which creates a small pouch at the upper end of the stomach. The surgeon must measure the size of this pouch very carefully; when completed, it is about 10% of the size of a normal stomach and will hold about a tablespoon of solid food.
After forming the pouch and checking its size, the surgeon takes a band made out of polypropylene plastic and fits it through the window around the outlet of the stomach pouch. The vertical band is then stitched into place. Because the polypropylene does not stretch, it holds food in the stomach longer, which allows the patient to feel full on only a small amount of food.
Following the placement of the band, the surgeon will check to make sure that there is no leakage around the window and the line of surgical staples. The area of surgery will then be washed out with a sterile saline solution and the incision closed.
A laparoscopic vertical banded gastroplasty, or LVBG, is performed with the help of a bariatric laparoscope. A laparoscope is a small (10 mm in diameter) tube that holds a fiberoptic cable that allows the surgeon to view the inside of the abdominal cavity on a high-resolution video screen and record the operation on a video recorder. In a laparoscopic VBG, the surgeon makes three small incisions on the left side of the abdomen for inserting the laparoscope, and a fourth incision about 2.5 in (14 cm) long on the right side. The formation of the stomach pouch and insertion of the plastic band are done through these small incisions. Because it is more difficult for the surgeon to maneuver the instruments through the small openings, an LVBG takes longer than an open VBG, about two to four hours.
A laparoscopic VBG requires that the surgeon spend more training and practice than with an open VBG. As of 2003, about 90% of VBGs performed in the United States are done as open procedures. In the event of complications developing during a laparoscopic VBG, the surgeon usually completes the operation using the open procedure.
DETERMINATION OF OBESITY. The diagnosis of a patient for bariatric surgery begins with measuring the degree of the patient's obesity. This measurement is crucial because the NIH and almost all health insurers have established specific limits for approval of bariatric procedures.
The obesity guidelines that are cited most often were drawn up by Milliman and Robertson, a nationally recognized company that establishes medical need for a wide variety of procedures for health insurers. The Milliman and Robertson criteria for a patient to qualify for weight loss surgery are as follows:
The patient must be treated not only by a doctor with special training in obesity surgery, but in a comprehensive program that includes preoperative psychological screening and medical examination; nutritional counseling; exercise counseling; and participation in support groups
There are several ways to measure obesity. Some are based on the relationship between a person's height and weight. The older measurements of this correlation are the so-called "height-weight" tables that listed desirable weights for a given height. The limitation of height-weight tables is that they do not distinguish between weight of human fatty tissue and weight of lean muscle tissue—many professional athletes and body builders are overweight by the standards of these tables. A more accurate measurement of obesity is body mass index, or BMI. The BMI is an indirect measurement of the amount of body fat. The BMI is calculated in English measurements by multiplying a person's weight in pounds by 703.1, then dividing that number by the person's height in inches squared. A BMI between 19 and 24 is considered normal; 25–29 is overweight; 30–34 is moderately obese; 35–39 is severely obese; and 40 or higher is defined as morbidly obese.
More direct methods of measuring body fat include measuring the thickness of the skinfold at the back of the upper arm, and bioelectrical impedance analysis (BIA). Bioelectrical impedance measures the total amount of water in the body, using a special instrument that calculates the different degrees of resistance to a mild electrical current in different types of body tissue. Fatty tissue has a higher resistance to the current than body tissues containing larger amounts of water. A higher percentage of body water indicates a greater amount of lean tissue.
PSYCHOLOGICAL EVALUATION. Psychiatric and psychological screening before a VBG is done to evaluate the patient's emotional stability and to ensure the expectations of the results of weight loss are not unrealistic. Because of social prejudice against obesity, some obese people who have felt isolated from others or suffered job discrimination come to think of weight loss surgery as a magical or quick solution to all the problems in their lives. In addition, the surgeon will want to make sure that the patient understands the long-term lifestyle adjustments that are necessary after surgery, and that the patient is committed to making those changes. A third reason for a psychological assessment before a VBG is to determine whether the patient's eating habits are compulsive; these would be characterized by the persistent and irresistible impulse to eat with unknown or unconscious purpose. Compulsive eating is not a reason for not having weight loss surgery, but it does mean that the psychological factors contributing to the patient's obesity will also require treatment.
OTHER TESTS AND EXAMINATIONS. Patients must have a complete physical examination and blood tests before being considered for a VBG. Some bariatric surgeons will not accept patients with histories of major psychiatric illness; alcohol or drug abuse; previous abdominal surgery; or collagen vascular diseases, which include systemic lupus erythematosus (SLE) and rheumatoid arthritis. Many will not accept patients younger than 16 or older than 55, although some surgeons report successful VBGs in patients over 70. In any event, the patient will need to provide documentation of physical condition, particularly comorbid diseases or disorders, to their insurance company.
Preparation for bariatric surgery requires more attention to certain matters than most other forms of surgery requiring hospitalization.
HEALTH INSURANCE ISSUES. Both bariatric surgeons and people who have had weight loss surgery report that obtaining preauthorization for a VBG from insurance companies is a lengthy, complicated, and frequently frustrating process. Insurance companies tend to reflect the prejudices against obese people that exist in the wider society. Although this situation is slowly changing because of increasingly widespread recognition of the high costs of obesity-related diseases, people considering a VBG should start early to secure approval for their operation. The American Obesity Association (AOA) has a pamphlet entitled, Weight Management and Health Insurance , a useful guide to the process of getting coverage for weight loss surgery. The pamphlet is available for free download from the AOA Web site.
LIFESTYLE CHANGES. A VBG requires a period of recovery at home after discharge from the hospital . Since the patient's physical mobility will be limited, the following should be done before the operation:
PRE-OPERATION CLASSES AND SUPPORT GROUPS. In line with the Milliman and Robertson guidelines, most bariatric surgeons now have "preop" classes and ongoing support groups for patients scheduled for VBG and other types of bariatric surgery. Facilitators of these classes can answer questions regarding preparation for the operation and what to expect during recovery, particularly about changes in eating patterns. In addition, they provide opportunities for patients to share concerns and experiences. Patients who have attended group meetings for weight loss surgery often report that simply sharing accounts of the effects of severe obesity on their lives strengthened their resolve to have the operation. In addition, clinical studies indicate that patients who have attended preop classes are less anxious before surgery and generally recover more rapidly.
MEDICAL PREPARATION. Patients scheduled for a gastroplasty are advised to eat lightly the day before surgery. The surgeon will provide specific instructions about taking medications prescribed for other health conditions. The patient will be given preoperation medications that usually include a laxative to clear the lower digestive tract, an anti-nausea drug, and an antibiotic to lower the risk of infection. Some surgeons ask patients to shower on the morning of their surgery with a special antiseptic skin cleanser.
Aftercare following a gastroplasty has long-term as well as short-term aspects.
Patients who have had an open VBG usually remain in the hospital for four to five days after surgery; those who have had a laparoscopic VBG may return home after two to three days. Aftercare in the hospital typically includes:
Long-term aftercare includes several adjustments to the patient's lifestyle:
Patients who undergo a VBG are at risk for some of the same complications that may follow any major operation, including death, pulmonary embolism, the formation of blood clots in the deep veins of the leg, and infection of the surgical incision. These risks are increased for severely obese patients; for example, the risk of infection is about 10% for obese patients compared to 2% for patients of normal weight. With specific regard to VBGs, recent studies indicate that the risks of complications after surgery are about the same for open and laparoscopic VBGs.
Specific risks associated with vertical banded gastroplasty include:
The long-term risks of vertical banded gastroplasty include:
The most rapid weight loss following a VBG takes place in the first six months. It usually takes between 18 and 24 months after the operation for patients to lose 50% of their excess body weight, which is the measurement used to define success in bariatric surgery. At this point, most patients feel much better physically and psychologically; diabetes, high blood pressure, urinary stress incontinence, and other complications associated with severe obesity have either improved or completely resolved.
The primary drawback of VBG is its relatively high rate of failure in maintaining the patient's weight loss over a five-year period. For this reason, some bariatric surgeons recommend VBGs for patients at the lower end of the severe obesity spectrum—those with BMIs between 35 and 40. The chief advantage of VBGs over malabsorptive types of weight loss surgery is that there is little risk of malnutrition or vitamin deficiencies.
Although bariatric surgeons advise patients to wait for two years after a VBG to have plastic surgery procedures, it is not unusual for patients to require operations to remove excess skin from the upper arms, abdomen, and other parts of the body that had large accumulations of fatty tissue.
According to the American Society of Bariatric Surgery, mortality following a VBG is about 5%. The rates of postsurgical complications are about 6% for leaks leading to infection and a need to reoperate; 4% for dehiscence; 1% for injury to the spleen; and 1% for pulmonary embolisms.
The primary restrictive alternative to a VBG is implanting a Lap-Band, which is an adjustable band that the surgeon positions around the upper end of the stomach to form the small pouch instead of using staples. The Lap-Band was approved by the Food and Drug Administration (FDA) for use in the United States in 2001. It can be implanted with the laparoscopic technique. When the band is in place, it is inflated with saline solution. It can be tightened or loosened after the operation through a portal under the skin. Although the Lap-Band eliminates the risk of dehiscence, it produces such side effects as vomiting, heartburn, abdominal cramps, or enlargement of the stomach pouch due to the band's slipping out of place. In one American study, 25% of patients eventually had the band removed.
The other major type of obesity surgery combines restriction of the size of the stomach with a malabsorptive approach. The combination surgery that is considered the safest and performed most frequently in the United States is the Roux-en-Y gastric bypass. In this procedure, the surgeon forms a stomach pouch and then divides the small intestine, connecting one part of it to the new pouch and reconnecting the other portion to the intestines at some distance from the stomach. The food bypasses the section of the stomach and the small intestine, where most nutrients are absorbed. The procedure takes its name from Cesar Roux, a Swiss surgeon who first performed it, and the "Y" shape formed by the reconnected intestines.
A newer technique in obesity surgery is known as gastric pacing. In gastric pacing, the surgeon implants electrodes in the muscle of the stomach wall that deliver a mild electrical current. These electrical impulses regulate the pace of stomach contractions so that the patient feels full on smaller amounts of food. Preliminary results from a team of Italian researchers on patients followed since 1995 indicate that gastric pacing is both safe and effective.
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Rebecca Frey, Ph.D.
A VBG is performed in a hospital whether the operation is an open or a laparoscopic gastroplasty. It is done by a bariatric surgeon, who is a medical doctor (MD) or doctor of osteopathy (DO) who has completed at least three years' training in general surgery after medical school and internship. Most bariatric surgeons have had additional training in gastrointestinal or biliary surgery before completing a fellowship in bariatric surgery with an experienced practitioner in this subspecialty. Because laparoscopic VBGs require more experience on the surgeon's part and take longer to perform, there are fewer surgeons who perform laparoscopic procedures. A survey done in 2000 by the American Society for Bariatric Surgery (ASBS) found that about 90% of bariatric surgeons perform open VBGs; only about 10% use the laparoscopic technique.
In addition to demonstrating the technical skills necessary to perform a VBG, bariatric surgeons seeking hospital privileges must show that they are competent to provide the psychological and nutritional assessments and counseling included in weight loss surgery programs.