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Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results

Crystine M. Lee¹, Paul T. Cirangle¹ and Gregg H. Jossart¹ 

(1)   Department of Surgery, California Pacific Medical Center, San Francisco, CA,

Received: 6 November 2006  Accepted: 5 January 2007  Published online: 14 March 2007

Abstract

Background  The vertical gastrectomy (VG) is the restrictive part of the technically difficult biliopancreatic diversion with duodenal switch operation (DS). The VG was originally conceived of as an independent operation—the first stage of a two-stage DS that would reduce mortality and morbidity in the high-risk superobese because of a shorter operating time and no anastomoses. This article presents two-year data after VG.

Methods  Laparoscopic VG was performed in a nonrandomized fashion in obese patients that met the NIH criteria for bariatric surgery. By using 5–7 firings of 45–60-mm linear 3.5-mm GI staplers along a 32-Fr bougie, a greater-curvature gastrectomy is performed and a 60–80-ml gastric tube is created. VG was compared to adjustable Lap-Band® placement, Roux-en-Y gastric bypass (RGB), and DS.  

Results  Between November 2002 and August 2005, 216 patients underwent VG. The mean age was 44.7 years (range = 16–64) and 173 (80%) were female. The mean preoperative weight and body mass index (BMI) was 302 ± 77 lbs and 49 ± 11 kg/m2, respectively. Of the 216 patients, 5 (2.3%) had a BMI > 80 kg/m2, 6 (2.8%) had a BMI of 70–80 kg/m2, and 25 (11.6%) had a BMI of 60–70 kg/m2. The mean operative time was 66 ± 11 min (range = 45–180) and the mean length of hospital stay was 1.9 ± 1.2 days. Complications occurred in 20 (6.3%) patients (vs. 7.1% after Lap-Band). Leaks occurred in 3 (1.4%) VG patients, reoperations were performed in 6 (2.8%), and no conversions to open or deaths occurred. Weight loss on par with the DS and RGB was achieved with just the VG alone.

Conclusion  The VG operation is able to achieve significant weight loss comparable to the RGB and DS operations but with the low morbidity profile similar to that of Lap-Band placement.

Abbreviations  Band adjustable gastric band placement - BMI body mass index - DS Hess’ biliopancreatic diversion and duodenal switch (also known as the vertical gastrectomy and duodenal switch) - EBL estimated blood loss - %EWL percentage excess weight loss - ICU intensive care unit - POD postoperative day - RGB Roux-en-Y gastric bypass - VBG vertical banded gastroplasty - VG vertical gastrectomy

Presented at the Plenary Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, TX, 28 April 2006

A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years.

Himpens J, Dapri G, Cadière GB.

Department of Gastrointestinal and Obesity Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, .

Background: Laparoscopic adjustable gastric banding (GB) is the most popular restrictive procedure for obesity in Europe. Isolated sleeve gastrectomy (SG), is less common, but more invasive and with a higher learning curve. The aim of this prospective randomized study was to compare the results of GB and SG after 1 and 3 years of surgery.

Methods: 80 patient candidates for laparoscopic restrictive surgery were operated consecutively and randomly, between January and December 31, 2002, by GB (7M, 33F) or by SG (9M, 31F) (NS). Median age was 36 (20-61) for GB versus 40 (22-65) for SG (NS). Median BMI was 37 (30-47) for GB versus 39 (30-53) for SG (NS). After 1 and 3 years: weight loss, feeling of hunger, sweet eating, gastroesophageal reflux disease (GERD), complications and re-operations were recorded in both groups.

Results: Median weight loss after 1 year was 14 kg (-5 to +38) for GB and 26 kg (0 to 46) for SG (P<0.0001); and after 3 years was 17 kg (0 to 40) for GB and 29.5 kg (1 to 48) for SG (P<0.0001). Median decrease in BMI after 1 year was 15.5 kg/m 2 (5 to 39) after GB and 25 kg/m(2) (0 to 45) after SG (P<0.0001); and after 3 years was 18 kg/m(2) (0 to 39) after GB and 27.5 kg/m 2 (0 to 48) after SG (P=0.0004). Median %EWL at 1 year was 41.4% (-11.8 to +130.5) after GB and 57.7% (0 to 125.5) after SG (P=0.0004); and at 3 years was 48% (0 to 124.8) after GB and 66% (-3.1 to +152.4) after SG (P=0.0025). Loss of feeling of hunger after 1 year was registered in 42.5% of patients with GB and in 75% of patients with SG (P=0.003); and after 3 years in 2.9% of patients with GB and 46.7% of patients with SG (P<0.0001). Loss of craving for sweets after 1 year was achieved in 35% of patients with GB and 50% of patients with SG (NS); and after 3 years in 2.9% of patients with GB and 23% of patients with SG (NS). GERD appeared de novo after 1 year in 8.8% of patients with GB and 21.8% of patients with SG (NS); and after 3 years in 20.5% of patients with GB and 3.1% of patients with SG (NS). Postoperative complications requiring re-operation were necessary for 2 patients after SG. Late complications requiring re-operation after GB included 3 pouch dilations treated by band removal in 2 and 1 laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP), 1 gastric erosion treated by conversion to RYGBP, and 3 disconnections of the system treated by reconnection. Inefficacy affected 2 patients after GB, treated by conversion into RYGBP and 2 patients after SG treated by conversion to duodenal switch.

Conclusion: Weight loss and loss of feeling of hunger after 1 year and 3 years are better after SG than GB. GERD is more frequent at 1 year after SG and at 3 years after GB. The number of re-operations is important in both groups, but the severity of complications appears higher in SG.

Laparoscopic Sleeve Gastrectomy is an Effective Primary Procedure for Morbid Obesity

Thomas Hirai¹, Hazem A. Elariny¹, Howard D. Reines¹, Michael Sheridan², Oscar Chan¹; ¹Surgery, Inova Fairfax Hospital, Falls Church, VA; ²Medicine, Inova Fairfax Hospital, Falls Church, VA (2001-2002)

Background: Sleeve Gastrectomy (SG) has gained acceptance as the first part of a 2-stage procedure in individuals with super morbid obesity (BMI>55), and has increasingly been suggested as a primary operation for morbid obesity.

Methods: 84 patients underwent SG from Feb. 2001 to May 2002. Forty six patients had a follow up > 1 year (average of 34 months). 32 patients had a BMI <= 55 and 14 patients had a BMI > 55. All patients were followed until a 2nd-stage procedure occurred or for the length of their follow up. Success was defined as an EBWL of >45%. Patients with BMI >55 were not subjected to the success/fail demark as 2nd stage intervention usually precluded this analysis. The SG procedure was performed using the lesser curve gastric tube fashioned over a 60F bougie.

Results: Of the 46 patients, 70% were females, average age was 40.5 years and average BMI was 51.9. There were no deaths, no leaks, and no re-operations for complications. Patients with BMI<=55, achieved success 66% of the time (21/32) and these patients achieved an average EBWL of 71% (95% CI = 65% to 78%). As compared to 11 failures (34%) in this group with an average EBWL of 23% (95% CI = 14% to 32%). This remarkable difference reached statistical significance (p <.0001).

Conclusion: These data show that over a 3 year follow up, SG performed as a primary procedure in MO patients with a BMI <= 55, is successful in fully two-thirds of patients and achieves an EBWL of 71%. These results are comparable to gastric bypass historical data. Although, longer follow-up and a larger cohort is required to validate these results and to assess the validity and efficacy of SG for patients with a BMI > 55, our data suggest that sleeve gastrectomy is a viable and reasonable alternative to gastric bypass.

Sleeve Gastrectomy and Gastric Banding: Effectson Plasma Ghrelin Levels

Background: Different changes of plasma ghrelin levels have been reported following gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion.

Methods: This prospective study compares plasma ghrelin levels and weight loss following laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in 20 patients.

Results: Patients who underwent LSG (n=10)showed a significant decrease of plasma ghrelin at day 1 compared to preoperative values (35.8 ± 12.3fmol/ml vs 109.6 ± 32.6 fmol/ml, P=0.005). Plasma ghrelin remained low and stable at 1 and 6 months postoperatively. In contrast, no change of plasma ghrelin at day 1 (71.8 ± 35.3 fmol/ml vs 73.7 ± 24.8fmol/ml, P=0.441) was found in patients after LAGB(n=10). Increased plasma ghrelin levels compared with the preoperative levels at 1 (101.9 ± 30.3 fmol/mlvs 73.7 ± 24.8 fmol/ml, P=0.028) and 6 months (104.9± 51.1 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.012) after surgery were observed. Mean excess weight loss was higher in the LSG group at 1 (30 ± 13% vs 17 ± 7%,P=0.005) and 6 months (61 ± 16% vs 29 ± 11%,P=0.001) compared with the LAGB group

Conclusions: As a consequence of resection of the gastric fundus, the predominant area of human ghrelin production, ghrelin is significantly reduced after LSG but not after LAGB. This reduction remains stable at follow-up 6 months postoperatively, which may contribute to the superior weight loss when compared with LAGB.

Well, it's pretty clear by now that I stink at journaling.  A lot has happened since my last entry.  In January I got "the call" inviting me to start the Kaiser approvals process.  I met with a weight loss specialist and a "cognitive behavioral specialist" (that's what they're calling shrinks these days), and got the go-ahead to start the classes. 

I also had a series of blood tests, and we learned that while everything else is pretty good, I had very low levels of Vitamin D, so I'm now taking Citrical plus D, 800 mg twice daily.  They were gonna put me on a prescription dosage, but since I've been able to make a habit of taking these pretty consistently, I was told I'm off the hook.

Classes have been a mixed bag.  I've appreciated the process, thinking through the habits I'm going to need to develop, trying to pick them up in advance, identifying triggers for overeating and finding ways to overcome them, etc.  But I honestly can't say I love the materials.  They try to tie the whole thing into a mountain-climbing metaphor, and it starts to get strained and kitschy along the way - I'm a writer, so this gets on my nerves pretty quickly.  Also, one of the teachers, for some reason, doesn't seem to like me and has taken a couple pot shots at me in front of the class, which I don't appreciate.  The first time I thought maybe I was being oversensitive, but it continued and eventually I concluded it was intentional.  But I'm not into confrontation, so I'm just trying to get through the class and get what I can from it. 

And I do feel mentally more prepared now than I did at the start of the class.  I'm still a little anxious about the idea that this is irreversible, and that some of my lifelong habits need to be broken forever - I'm making headway, but "forever" is a long time.  But at the same time I have confidence that the procedure will be a tool to help me make these changes.  I know from hard experience how little I have to eat to lose weight and maintain a lower weight, and when I do that now I'm hungry all the time and food-obsessed all the time, trying to overcome the hunger by planning what I'll eat the next time I can eat.  This will make it so that I'm not so hungry, and when I do eat I can't eat as much.  It will make it so that the calorie intake is where it should be without me feeling deprived all the time. 

This week, I should get a chance to request surgery dates, and I meet again with the shrink, this time to talk about food more in-depth than before.  I imagine that this is probably the make or break meeting as far as approvals.  Also I have another blood test to see if my vita-d is up where it should be. 

Hopefully I will be getting on with this by May!!!

Anyone who needs a shepherd through the Kaiser Weight Loss Surgery process is welcome to contact me!

Lisa

I got Kaiser's notice last Friday, telling me that I was admitted to the Surgical Weight management program.  And today, I met with a Kaiser doc, who chatted with me at some length (not your typical rush-rush Kaiser doc) about my weight, my eating habits, and generally my surgical direction.  I told him I have a strong preference to have the gastric sleeve procedure.  He told me essentially that had I entered the program just a few short months ago, the answer would've been no. BUT one of the clinics that Kaiser works with has hired a new surgeon, who is in the process of being credentialed with Kaiser, who does the VSG.  Kaiser's policy is that they do not determine the surgery the patient will have.  That decision is up to the patient and surgeon.  So by the time I get through the classes and preliminary stuff in six to eight months, I should be able to ask to see this surgeon, and if he agrees that VSG is a good option for me, there should be no problem getting it approved. 

The timing of this just seems uncanny.  JUST when I start really looking into this, JUST when I decide that this is the right procedure for me, they just "happen" to have a new doc coming in.  Wow!  All I can say is God is good.

Now to get my buttocks on that treadmill and start developing good habits and getting my heart healthy for the surgery!!!

I went digging on the various medical research sites and pulled a bunch of clinical studies.  They're posted as a single word document at www.vsgfaq.com under General Information, if you want a copy for yourself.  Go to General Information.  About a third the way down, you'll see Studies and Research.  Then the third and fourth links down take you to the word documents.  The first is 22 pages - a collection of 19-20 abstracts for studies on various aspects of VSG.  The second is the full text of one study, which contained a lot of good information that may help with conclusions about the durability of weight loss with VSG.  

These may help you do battle with insurance companies, as well.  Good luck! 
Lisa

8/15/07.  I'm just getting started on my WLS journey.  I've looked into the various options off and on for a few years, but always balked at the inconvenient side effects.  It seemed a drastic thing to do, and I figured if I'd just get a little more disciplined, I could drop the weight myself.  Well, at 47 yoa, 282 lbs (highest was 304 - never want to go there again), pre-diabetic, borderline BP, I decided that my own efforts are not working so well.  God has a way of pounding that point home with me.  So I put in my application on Monday for Kaiser's weight loss surgery program.  I have an uphill battle ahead, because I'm only willing to have a VSG.  If Kaiser won't approve, I will either A) hire an attorney, B) fire the insurance company at my job's annual open enrollment and try through a new insurer, or C) take out a loan, pray for no complications, and go self-pay.   Prayers for wisdom and favor would be greatly appreciated!