Surgical Treatment of Obesity

Vertical Banded Gastroplasty

The gastric restrictive procedures are performed in many medical centers. One of the most widely used procedures is the vertical banded gastroplasty (VBG) sometimes with additional reinforcement of a small silastic ring.  In VBG, the stomach is "stapled" to reduce its capacity to approximately 15 ml. (1/2 oz.) and a silastic ring is inserted to help prevent the stomach from "stretching" in size. What is formed is essentially a small stomach "pouch" that receives food from the esophagus and a much larger, unstapled stomach that receives small amounts of food from the proximal "pouch". When one eats, only a small amount of food can be consumed without the pouch becoming distended. This generally leads to a feeling of satiety or fullness. If one continues to eat, one will develop nausea, vomiting, or pain, which generally results in the termination of eating. Patients must adapt to their new, restricted stomach size and restrict their food intake to prevent these side-effects. Complications can result from the surgery. When gastroplasty is done by well-trained physicians, the mortality (death rate) from the surgery is under 1 %.

Complications include risk of infection, obstruction (blockage) of the outlet necessitating surgical revision, development of blood clots in the legs or lungs, bleeding, metabolic or nutritional deficiencies (including protein calorie malnutrition), and recurrent vomiting. It is not uncommon to slowly develop vitamin (especially vitamin B-12) and mineral deficiencies resulting in anemia or osteoporosis (softening of the bones). After the surgery, the patient must be followed by physicians who are familiar with the long-term complications and required long-term treatment.

The effectiveness of the surgery is fair with average weight loss being between 50 and 100 lbs. (or about a loss of about 25% of initial weight) with about 50% of the weight loss being maintained at 5 years. It is generally common for the body weight to slowly increase after the first or second year. The surgery requires a modified diet to prevent nausea and vomiting and to help prevent other long-term side effects. Additionally, one can (partially) bypass the "restriction" by eating calorie-dense liquids such as ice cream or regular soda. Long-term changes in eating habits must take place in order for the surgery to be successful. Vertical Banded Gastroplasty, however, is a viable treatment alternative for severely overweight individuals but again, it is not a cure.

Gastric Banding

Another approach which has recently been popularized is laparoscopic gastric banding. This procedure, which was approved in the U.S. in June 2001, is popular since it is "high tech" (utilizes a laparoscope, an instrument which is inserted into the abdominal cavity) and recovery time is only a few days. Basically, an adjustable band is placed around the upper portion of the stomach resulting in a much smaller stomach. This restricts the amount of food that can be eaten, similar to the vertical banded gastroplasty (see above).

The European literature (where the procedure has been performed for the last few years) show that weight loss is similar to the weight loss seen with vertical banded gastroplasty. The European literature thus far shows a relatively low incidence of side effects and surgical complication.

A major concern with this surgery is that it is, in essence, an old surgery (gastric banding) that was abandoned in the 1980's because of a high incidence of complications (bleeding and obstruction). Although this new approach is less invasive than the "old" banding procedure and the band is adjustable, this procedure is in essence a take-off on a bad basic procedure (gastric banding) which will likely result in the same long-term complications that occurred with the "old" surgery.

Gastrointestinal bypass procedures

A current variation of the intestinal bypass and one that is becoming more popular is the Roux-en-Y Gastric Bypass. This procedure involves decreasing the size of the stomach by stapling across the top of the stomach and then bringing-up and attaching a portion of the small intestine directly to the stomach (thus bypassing part of the small intestine). This surgery is much better tolerated than the "old" intestinal bypass but still results in significant complications, such as vitamin and mineral deficiencies, and may lead to osteoporosis (softening of the bones) in the long-term. 

There is usually only mild malabsorption of nutrients (as compared to the old intestinal bypass surgery).  Individuals undergoing this surgery will lose significant amounts of weight (mainly fat as opposed to lean body mass or muscle tissue) with about 50-60% of excess body weight being lost initially. Weight maintenance is generally excellent with usually only small increases in weight occurring over 5 years. Like any obesity surgery, the patient will require lifelong medical follow-up and treatment of the medical complications that usually occur (e.g., vitamin B12 deficiency and anemia).

This procedure can now be done laparoscopically, which offers a faster surgical recovery but with the potential of more severe surgical complications since it is a technically difficult procedure. The availability of new state of the art 3-D visualization equipment may make the laparoscopic Roux-en-Y Gastric Bypass the procedure of choice for individuals electing to undergo surgical intervention for their obesity.

For a QuickTime movie (208 KB /approximately 60 seconds download with 28.8 modem) illustrating a a roux-en-y bypass, please click here (animation compliments of Vista Medical Technologies). If you don't have QuickTime, you may download it from Apple Computer (it works great on Macs and PC's) by clicking here.

Biliopancreatic bypass procedures (and similar extensive intestinal bypass procedures)

In these procedures, the digestive juices from the liver and pancreas are diverted to the distal small intestine near the entrance to the large intestine.  Thus, food enters the stomach, rapidly transverses the distal small intestine (where absorption of nutrients primarily occurs), and is then delivered to the large intestine (where excess water from the stool is removed). This results in marked malabsorption of nutrients with subsequent marked weight loss (up to 80% of excess body weight). Since there is marked malabsorption of essential nutrients, the probability of vitamin, mineral, and protein-calorie malnutrition is significant. These procedures are probably best avoided at this time since the marked nutrient malabsorption may result in very severe long-term complications that may be similar to the old intestinal bypass operation.

Last modified: August 2001.

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