Innovations in Weight Loss Surgery
by Nikki Johnson and Niloo E Sarabi
Weight loss surgery is constantly changing as we learn more about the mechanisms of weight loss. Many of the changes are being driven by surgeons who aren?t afraid to innovate, such as Eldo Frezza, MD, MBA, FACS, a professor at Texas Tech University Health Science Center in Lubbock, Texas, and author of Slim the Italian Way?A Weight-Loss Surgeon?s Guide to Losing Weight. Dr. Frezza has put a relatively old procedure?vertical sleeve gastrectomy (VSG)? to a new and controversial use: gastric banding with stomach reduction (GBSR).
How exactly the VSG began is not certain, but it has a long history. According to Dr. Frezza, surgeons in Japan used a similar technique in the treatment of tumors in the 1980s. There is reference to a similar operation in France in 1993. Many people believe that VSG as we now know it was started in the 1990s by the internationally renowned bariatric surgeon Michel Gagner, MD, FACS, FRCS.
Dr. Frezza explains that the VSG operation differs from some of the other popular weight loss surgery methods because it involves the removal of a part of the stomach. Dr. Frezza says, ?This is a very important concept. For instance, in the vertical banded gastroplasty, we staple parts of the stomach, but the stomach remains inside the abdomen. In the case of the sleeve gastrectomy, however, we staple and suture at the same time, so a part of the stomach comes out.? Why is this important? Because the removal of the fundus?the upper portion of the stomach?has a profound impact on how and why the surgery functions.
?After we started performing this operation,? Dr. Frezza says, ?we had important findings that began with studying the basic science of why the operation works. An article by Dr. Calle was published in the New England Journal of Medicine a few years ago about the production of ghrelin, which is a hormone of appetite and satiety. Ghrelin acts centrally at the level of hypothalamus, but it is produced by the fundus, in the body of the stomach. Therefore, we found that by resecting the stomach and the fundus, we resect the hormone-producing part of the stomach.? It is believed that the removal of the part of the stomach that produces ghrelin impacts the endocrine system and helps reduce the appetite. That makes the operation both metabolically active, such that it impacts hunger and metabolism of nutrients, and restrictive, meaning that the reduced stomach holds less food.
Dr. Frezza says that when VSG surgery was developed, it was intended as a first-stage operation to jump-start weight loss for the heaviest patients. Patients with a BMI of 60 or 70 would be given the VSG operation to bring their BMIs down to 50 or 60. Then, they would have a duodenal switch or a gastric bypass to help them finish the weight loss process. But something surprising happened in many cases. Dr. Frezza explains: ?When I started performing vertical sleeve gastrectomy in my super-obese patients, I found that the patients were losing enough weight that they did not want the second-stage procedure. So I started offering [VSG by itself], [with a] very strict consent form and explanation to make sure that they knew that this was still an experimental procedure.? Now, a number of Dr. Frezza?s patients choose the VSG operation knowing that they may not need the second-stage operation, but they can choose to have it if they do.
That VSG is effective has been clear for many years, but it may be a long time before science can explain all the details of how and why. Whatever the mechanism of VSG, the results have been encouraging. Dr. Frezza says that between three and five years after surgery, most patients lose 60 percent of their excess weight, as opposed to the 50 percent weight loss with gastric banding and vertical banded gastroplasty (VBG). While VSG is not as effective as the duodenal switch (DS), it has a few advantages over the DS that some people may find compelling.
According to Dr. Frezza, the main advantage is that VSG is safe and easy to perform. He adds, ?The gastric bypass and duodenal switch are more technically demanding. The mortality rates are lower than gastric bypass and duodenal switch. If we can achieve 60 percent excess weight loss with an operation that is easier, has lower complication rates and requires only one night?s stay in the hospital, I think a lot of patients would choose this operation over an operation that will give them about 70-75 percent weight loss, like a duodenal switch, which has more potential complications. Additionally, some patients don?t like to have malabsorptive procedures, which mean the rearrangement of the intestines. For that reason, VSG will be really appealing to the patients who do not want to worry about potential long-term nutritional issues.?
VSG is usually performed laparoscopically, with essentially the same incisions as laparoscopic gastric banding. According to Dr. Frezza, because it is a simple procedure, it is also faster than some of the other popular operations, so the patient stays under anesthesia for a shorter time. As with any operation, there is potential for complications, but they tend to occur less frequently with the VSG than with the Roux-en-Y gastric bypass.
VSG is no longer simply for patients with BMIs of 60 or 70, though most centers prefer to reserve it for people with the most weight to lose. In his practice, Dr. Frezza offers the VSG to patients with BMIs from the 30s to the 70s. He says, however, that the super-obese patients are good candidates for this procedure because the VSG is a great tool for lowering their BMIs to the point that they can choose to have a more traditional bariatric operation.
For Dr. Frezza, VSG has become a platform for a controversial bariatric innovation. He says that the controversy mainly stems from the fact that the new operation utilizes a staple line, which creates the potential for leaks and infection. He explains how he tries to reduce this risk by saying, ?I cover the band with the fundus, and then staple the stomach. [?] I don?t place the band on top of the staple line to minimize the chances of an infection.? This method means that less of the fundus is removed, which may reduce the effectiveness of the VSG portion of the operation, but the adjustable band will do its part to help promote additional weight loss. Patients do not need their first adjustment until six months after surgery, which is a huge advantage for Dr. Frezza?s patients, since they drive an average of 10 hours to get to his office.
Some of Dr. Frezza?s colleagues have criticized his choice to perform the GBSR because of the potential for infections, but Dr. Frezza is quick to point out that for some patients, that risk is worth taking because of the benefits. He says, ?My patients? main concern is being able to make it to the follow-up visits due to the high transportation costs. Therefore, I think that [GBSR] is a good procedure in patients with banding who wanted to lose more weight in the first six months and not be bothered with too many follow-up visits, which demand more money to invest in travel and doctor?s appointments.?
Whether GBSR will catch on more widely remains to be seen. Whatever may happen, GBSR will certainly remain an example of how bariatric procedures evolve as surgeons like Dr. Frezza try to find the most effective methods of weight loss for their patients.
Why did you choose VSG?
I?ve been working toward my VSG since late last summer. I started looking into WLS a couple years ago when my sister had RNY. There were turnoffs for both of the other major procedures. I liked that Lap-band was adjustable, but then I started reading about the problems people had with ?sliming? and blockages and more serious problems like slippage and erosion. Plus, I don?t know that I can trust that the parts will all hold up for the 30-40 more years I hope to live, and don?t want to deal with additional surgeries to fix things. With RNY, dumping sounds dreadful, and I worry about the long-term effects of malabsorption?will vitamin supplements be sufficient when you?re 80 and having even more problems with absorbing nutrients? My mom has celiac disease (CD), a malabsorptive disorder involving the same kinds of issues, and I have a risk of getting it too. What if I had an RNY and then got CD as well? So when I read about VSG, it seemed like a godsend. No malabsorption, no implants that could break down, no dumping, no sliming?just plain old restriction plus reduced hunger! I read every study I could find, and emailed the office of Drs. Cirangle and Jossart to see if they had followed patients for more than five years and whether the weight loss thus far on those older patients was durable. They said it was. We may not have 10-year data, but it seems to me that if the weight loss at three to five years is durable, that says enough. We do have longer-term data on the similar Magenstrasse and Mill procedure.
Then I went to work finding a surgeon who did the procedure near home. Turns out my insurance (Kaiser) was just credentialing a surgeon who does the procedure, and, surprise of surprises, even though the gatekeepers at Kaiser said they only approved RNY and Lap-band, I learned that Kaiser would approve me for VSG if my surgeon agreed. This was the confirmation I needed. I have just gotten through Kaiser?s pre-op weight loss program and I?m preparing for surgery.
OH member LKH, patient of Matthew Metz, MD