Gastroplasty

• What is gastroplasty?
• Why is the procedure performed?
• What are the benefits of gastroplasty?
• What are the risks of gastroplasty?
• How are patients prepared for the surgery?
• What is involved in the surgery?
• What happens after the surgery?

What is gastroplasty?

Gastroplasty is a weight loss operation available for the management of morbid obesity. It is a restrictive procedure in that it limits and reduces the amount of food intake possible, as opposed to the alternative procedures such as gastric bypass which work by reducing the absorption of calories through the digestive tract. Its main advantage is that is does not affect the normal digestive process, thereby limiting nutritional deficiencies which are often associated with the former procedure.

This procedure is also known as ‘stomach stapling’ as it involves vertically stapling the upper part of the stomach into a small pouch of about 20-30mL which is then connected to the rest of the stomach through an small outlet (stoma) of about 10-12mm width. At the lower end of the pouch a band or mesh is often placed to prevent the outlet from widening. The pouch restricts the amount of food that can be eaten at one time because of the slow passage of the food into the remaining stomach which subsequently helps maintain a feeling of fullness.

Gastroplasty was initially introduced in 1971 following the advent of surgical staples and was supposedly to provide a simpler and safer alternative to gastric bypass surgery which was often associated with many complications such as micronutrient deficiency and peptic ulcerations. It has had several revisions made to it since its introduction. The earliest methods involved horizontal stapling of the stomach which divided it into a smaller upper section and larger lower part which was connected by a channel. However this was unsuccessful in maintaining weight loss because of inevitable stomal widening. In 1981 vertical gastroplasty was introduced and again initial methods resulted in breakdown of staples and stomal enlargement and were soon modified by the addition of a band or silastic ring around the stoma to support the outlet and prevent it from stretching. This modification was known as vertical banded gastroplasty (VBG) and is what is what is used today.

VBG can be carried out as open surgery or laparoscopically. The first laparoscopic VBG was performed in 1993 and is now more commonly performed because of the reduction in complications associated with wounds such as infection and incisional hernias.

Gastroplasties are becoming less widely used now with the introduction of the adjustable gastric banding technique which is simpler and avoids incision of the stomach and the use of staples. World-wide VBGs comprise around 5% of all weight loss operations, thus making it the third most common surgery for obesity. In Australia however, it is performed with much less frequency due to it’s high long term re-operation rate of about 20%. In Australia the most common procedure is laparoscopic adjustable gastric banding (LABG) which is carried out in more than 90% of cases.

Why is the procedure performed?

Weight-loss surgery is performed to aid morbidly obese patients lose weight, as their weight often impacts significantly on their health and state of mental well being. Often they will also be suffering from other life threatening or debilitating illnesses such as heart disease, diabetes, depression, sleep apnoea and osteoarthritis.

The suitability of a patient for gastroplasty is essentially the same as for all weight-loss surgeries. Certain guidelines are set by the National institutes of health (NIH) and the National Health and Medical Research Council (NHMRC) which outline selection criteria that must be taken into consideration before a doctor can recommend weight loss surgery:

• Weight greater than 45kg above ideal body weight for sex, and height.
• Body mass index (BMI) greater than 40 by itself or greater than 35 if there is an associated obesity illness, such as diabetes or heart disease
• Several previous attempts already made using other non-surgical weight loss techniques
• Aged between 18-65 years
• Has been at current weight for 3-5 years
• Has obesity related health problems 
• No drug and alcohol dependency problems or major psychiatric illness
• Capable of tolerating surgery
• understands the risks and long term commitment associated with the surgery.
• Patient motivation and willingness to commit to behavioural and lifestyle changes following surgery and is committed to long term follow up.
• Is not pregnant and not planning a pregnancy within the first two years after surgery

Click here to calculate your BMI.

There are some exceptions to this and patients as young as 12 have been offered surgery. Sometimes a lower BMI of 30-35 is accepted if a patient is also suffering from hypertension, diabetes mellitus, hyperlipidema, severe osteoarthritis or sleep apnoea.

What are the benefits of gastroplasty?

Gastroplasty is generally a quick and safe procedure in comparison to many of the other weight loss operations and now with laparoscopic method available also reduces the risk of certain complications. It also has a very low mortality rate in comparison to other surgeries. The procedure is reversible as the digestive tract is left intact and there is also less risk of infection.

Because gastroplasty does not involve alterations of the anatomy of the gastrointestinal tract there are no effects of such as those seen in malabsorption surgeries. Nutritional deficiencies such as anaemia are uncommon with less than 3% of those undergoing VGB experiencing deficiencies as opposed to 17% patients with gastric bypass. In addition, maintaining a normal anatomy also allows passage of an endoscope if necessary later on.

As with most bariatric surgeries the resulting weight loss can help reduce the effects of co-morbidities such as cardiovascular disease, hypertension and diabetes. One study found it reduced the risk of cancer incidence.

What are the risks of gastroplasty?

VBG is losing favour over other forms of bariatric surgery, mainly because it has been the least successful in maintaining weight loss long-term. It is also the procedure which produces less weight loss initially. VBG patients can lose about 40-50% of their excess body weight over the first two years but this drops to 20% after three years. Several studies have found that patients undergoing gastroplasty lose around 10kg less than those undergoing with Roux-en-Y Gastric Bypass (RYGB) at 12 and 36 months post surgery with the average weight loss around 32 kg compared to 42kg for gastric bypass. The main contributing factors to late weight gain are expansion of the pouch, staple line breakdown and migration of the band supporting the outlet.

Following surgery patients are required to adhere to a very strict diet and must follow advice on how to eat food to avoid problems. Reversal of gastroplasty is carried out in about 4% of patients because of food intolerance. Vomiting and severe discomfort is experienced if food is not properly chewed or if food is eaten too quickly.

Maladaptive eating behaviours can occur which also contributes to weight gain. One such behaviour is the ‘soft calorie syndrome’ where patients tend to ingest ice-cream and high calorie soft drinks which easily pass through the narrow outlet from the pouch. Highly refined foods also tend to be easier to eat while high fibre foods such as fruit and vegetables are very difficult so many patients slowly regain weight lost after surgery by consuming more calorie rich foods.

VBG is not adjustable like gastric banding, however it can be reversed or converted to a gastric bypass.

Complications

The most common complications associated with VBG are obstruction, leakage from the stomach, outlet stenosis, pouch dilatation, ulcers, incisional hernia, fistulas, wound infections, band erosion, staple line disruption and bleeding from the staple line and rarely, pulmonary complications.

Stenosis may occur from infection of the material supporting the stoma or a reaction of the scar tissue around it. It may manifest as deterioration of ability to eat solid food and regurgitation. Heartburn is a consequence of this and patient may have to resort to a liquid diet.
 
Leakage from the stomach usually manifests as tachycardia with severe abdominal pain and a subsequent increase in body temperature. Patients may experience difficulty breathing and pain in the left shoulder.

Thromboembolic disease in not common but can be life threatening. To avoid this, patients should be encouraged to get up and walk around early on after surgery. Other preventative measures that may be taken include administration of low dose heparin for the duration of the hospital stay.

Mortality associated with VBG is very low (0-1.7%) with pulmonary embolus being most common cause of death. Mortality is also related to the experience of the surgeon.

Generally, laparoscopic procedures require a shorter recovery time and have a reduced incidence of wound infection and incisional hernias compared with open surgery. However, it appears that the re-operation rate is higher with laparoscopic procedures.

Long term complications

A ten year follow-up study found that the most common long term complications were, staple line disruption, mechanical or functional stomal obstruction and maladaptive eating behaviours. A high incidence of persisent vomiting, heartburn and dumping is also common. Most importantly only 26% of patients maintained weight loss after ten years.

Late complications that require re-operation include the onset of gastroesophageal reflux, staple line fistula, food intolerance, pouch enlargement and incisional hernias.

How are patients prepared for the surgery?

Evaluating a patient who is interested in bariatric surgery is complex and often involves collaborations between the surgeon, a nutritional specialist and a psychologist. A patient’s medical history and a full physical examination is conducted in order to identify any risk factors such as hypertension, type 2 diabetes and hypoventilation syndrome. A dietician is also involved in assessing a candidate’s relationship with food and eating behaviours. Patients need to be well informed of all aspects of the procedure including the risks, benefits, side effects, and expected weight loss. Particular emphasis must be placed on the importance of making permanent dietary and lifestyle changes to ensure long-term the success of the surgery and to reduce the chance of weight gain and other complications. Patient motivation and willingness to adhere to all post-operative dietary recommendations is the key to ensuring long term successful weight loss.

Surgeons can only do so much and the rest is up to the patient. They must be willing to modify their eating habits and understand the effects on eating techniques following surgery.

What is involved in the surgery?

VBG is performed under general anaesthetic and takes about one hour. The procedure involves making a hole in both layers of the stomach with a circular stapling device to create an opening through which a stapler could be passed. The stomach is then divided using staples to create a small pouch closest to the oesophagus. The end of the pouch is narrowed to create a small outlet of about 10-12mm width which leads into the remainder of the stomach. This outlet is reinforced with a silastic ring which prevents it from stretching.

Following gastroplasty surgery, patients will feel full after eating only small amount of food and also stay full longer thus leading to a drastic reduction in calorie-intake. Most weight loss occurs in the first six-months to a year following surgery. Further success is dependant on a patient’s compliance with a strict diet and exercise regime.

What happens after the surgery?

Usually patients can be discharged from the hospital 3-4 days after surgery. If a laparoscopic procedure was performed then they may be able to leave even earlier.

In order to prevent discomfort and complications patients are required to follow a very strict diet, especially in the weeks after surgery. It is recommended that only liquids are ingested in the first 1-2 weeks post surgery followed by soft pureed food for three more weeks before commencing on solids. Patients are advised on the correct technique when eating such that obstruction does not occur.

Those adhering to strict follow-up and regular monitoring with their surgeon and dietician are more likely to have successful outcomes. A strict eating plan and exercise regime should be made early on and commenced immediately following discharge.

Eating and drinking at the same time should be avoided as food will be washed down into the distal stomach and the feeling of fullness will not be achieved.

Ultimately it is up to the patient to ensure long term success of their surgery. They must be willing and motivated to comply to all dietary and lifestyle changes recommended. Ongoing social and psychological support will be necessary in achieving this.

More information

For more information on obesity, health and social issues, and methods of weight loss, as well as some useful tools, see Obesity and Weight Loss.

References

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