Gastroplasty

The term gastroplasty refers to the reshaping of the stomach to decrease its capacitance as a food reservoir. The early satiety induced by these restrictive procedures causes weight loss through decreasing caloric consumption. This is in distinction to malabsorptive operations such as the jejunoileal bypass and the biliopancreatic diversion, which decrease the number of calories that are being absorbed.

Advantages to gastroplasties compared to Roux-en-Y gastric bypass include the decreased risk for vitamin and mineral deficiencies, the lack of dumping syndrome, and the decreased immediate surgical complication rate, especially abdominal infections. Unfortunately, late-term problem such as poor weight loss and severe reflux have severely limited the application of these procedures.

Gastroplasty was the first purely restrictive operation performed for the treatment of obesity. Gastroplasties are typically divided into two types: the horizontal, and the vertical banded gastroplasty. The horizontal gastroplasty was first developed in the 1970s as an alternative to the Roux-en-Y gastric bypass and the jejunoileal bypass. The horizontal gastroplasty is performed by placing a set of staples transversely across the uppermost portion of the stomach, thereby separating the stomach into two parts.

A small channel is preserved between the upper pouch and lower stomach to maintain an outflow (stoma) for food to pass. The staples act as a seam that physically decreases the capacitance of the stomach. The lay term stomach stapling comes from this procedure. Unfortunately, late weight-loss failures were common, as the seam would invariably “pop” open, leaving the stomach in its native configuration. Due to weight regain, this procedure has been abandoned.

The vertical banded gastroplasty (VBG) is performed by orienting the staples in a vertical fashion against a bougie (sizing device) placed along the lesser curve of the stomach. The new stomach tube is made approximately one to two ounces in volume and just a few centimeters in diameter. To prevent dilation of this vertical channel, a prosthetic band is wrapped around the channel. Various materials are [Page 316]used such as polypropylene, Silastic®, and even an adjustable gastric band.

The VBG is now rarely performed, as long-term studies have shown a significant percentage of long-term failures. Failures are either secondary to weight regain due to stomal dilation or severe reflux due to stomal stenosis (narrowing of the opening). Failures often respond to conversion to the Roux-en-Y gastric bypass. Erosion of the band into the stomach is another serious complication that is not uncommon. Randomized trials have found this operation inferior to the Roux-en-Y gastric bypass, especially in candy eaters. This procedure is waning in popularity as only a few surgeons still perform this operation.

Another reason that the VBG has become in disfavor is the decrease in complications with the Roux-en-Y gastric bypass procedure. The gastric bypass, when performed by experienced surgical centers has a mortality rate of 0.2 percent and can be performed laparoscopically in nearly all instances. Restrictive procedures have given significant insight in the causes of obesity. From these operations, it has become evident that the feelings of fullness and hunger are much more complex than the size of the stomach pouch. The weight loss with the VBG and the adjustable gastric band are significantly less than the gastric bypass possibly secondary to the more profound changes in neurohormones such as ghrelin, PYY, and leptin in the later procedure.

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