Vertical Banded Gastroplasty (VBG)
What Is Vertical Banded Gastroplasty?
In simple terms, bariatric “gastroplasty” is an operation during which the stomach is reduced in size using special staples, in order to restrict food intake and thus cause weight loss. Unfortunately, the use of staples in this way has one big drawback: the stomach wall tends to stretch. This was why early stomach stapling operations (eg. Horizontal Gastroplasty) proved ineffective. Then, in 1980, Dr. Mason, the Professor of Bariatric Surgery at the University of Iowa developed a new method of gastric stapling. His method, known as Vertical Banded Gastroplasty or VBG, overcame many of the problems of horizontal gastroplasty by utilizing a vertical row of staples across a less stretchy part of the stomach. In addition, vertical banded gastroplasty uses a gastric band as a collar to maintain the restriction of the stomach. During the 1980s and 1990s, vertical banded gastroplasty was the most common type of “restrictive” obesity surgery. It has since been superceded by adjustable gastric banding methods (eg. Lap-Band), which avoid the use of stomach staplers and rely exclusively on gastric bands or silastic rings.
How Does Vertical Banded Gastroplasty Work?
VBG is a “restrictive” form of bariatric surgery, meaning, it aims simply to restrict the amount of food and calories which patients consume, thus helping them to lose weight. Unlike stomach bypass operations (eg. Roux-en-Y), VBG does not alter the gastrointestinal digestive tract by bypassing the stomach or any part of the small intestine. Instead, it divides the stomach into two sections: an upper small pouch, and a lower larger section. The two sections are linked by a narrow passageway called the “stoma”. VBG achieves two things: first, the tiny size of the pouch (effectively the new stomach) makes patients feel “full” after only a couple of tablespoons of food. Second, the narrowness of the stoma slows down stomach emptying and thus prolongs the feeling of fullness or satiety. In this way, vertical banded gastroplasty helps patients to restrict calorie intake and reduce weight.
How Is The Vertical Banded Gastroplasty Operation Performed?
VBG may be performed laparoscopically or by traditional open surgery methods (laparotomy). If using laparoscopic techniques, the bariatric surgeon begins by making a series of small incisions in the abdomen. Special thin instruments, including a laparoscope (a tube with a camera at the end) are inserted through the incisions and are used to conduct the operation. The surgeon views the site of the operation on a video screen linked to the laparoscope. VBG may also be performed using the open surgical method. In this procedure, a single large incision between breast-bone and navel is used to expose the operational site.
What Happens During The Vertical Banded Gastroplasty Operation?
VBG is conducted under general anesthesia and the operation lasts for about 60 minutes. The surgeon implants a 2.5 inch line of gastric staples on a vertical segment of the lesser curvature part of the stomach in order to divide the stomach into two sections – an upper (proximal) stomach pouch the size of an egg, and a lower (distal) stomach section. The surgeon leaves a small passageway (stoma) about 1/4 inch wide in the staple-line to permit food to pass from the pouch to the rest of the stomach but at a very slow rate. To reduce the possibility of the stoma stretching, a silastic gastric band is placed around the stoma. This maintains the integrity of the food restriction.
What Happens After Vertical Banded Gastroplasty?
Typically a number of post-op follow-ups are arranged to remove stitches/sutures, check the gastric band and monitor patient condition for health complications after the operation. VBG patients also receive extensive instructions on diet, exercise and nutrition. Adherence to these post-op guidelines is essential to reduce side-effects and optimize weight loss. The hospital or bariatric clinic may offer additional post-op support via patient support groups or online facilities.
VBG patients typically stay in hospital to recover for 2-4 days after the operation. Most patients can resume ‘most’ normal activities within 3-5 weeks. Typically, many patients are able to return to light work in about 10 days. If the vertical banded gastroplasty is performed laparoscopically, these recovery and recuperation times are usually significantly reduced, although bariatric surgeons recommend all patients to avoid any form of strenous activity for about 6 weeks after their operation.
What Foods Can Patients Eat After Vertical Banded Gastroplasty?
A typical diet plan after VBG starts with liquids only then gradually widens to include semi-solids and finally solid food. The exact dietary regime will depend on the health and condition of the patient. As a general guide, VBG patients are restricted to clear liquids for several days, proceeded by a mainly liquid diet of low fat, low sugar, low calorie liquids and soups for about 3-4 weeks. Thereafter, soft high-protein foods may be consumed, followed by soft meats, fruits, vegetables and grains. Patients must chew all food thoroughly. A dietitian is always available to advise on nutritious food options and on the need for nutritional supplements in case the quantity of food consumed is unable to meet the patient’s nutritional requirements.
How Does Vertical Banded Gastroplasty Cause Weight Loss?
After VBG, the new stomach pouch accomodates only about one tablespoon of solid food, thus patients typically feel full after other a couple of mouthfuls, and stay full for longer. This, together with a temporary feeling of discomfort while the patient adjusts to their new eating pattern, leads to a drastic reduction in calorie-intake. The greatest weight loss occurs in the first six months after surgery. Further success is determined by the degree of patient compliance with their diet and exercise guidelines.
How Much Weight Do You Lose After Vertical Banded Gastroplasty?
Exact rates of weight loss after vertical banded gastroplasty are hard to establish. Evidence suggests that about 1 in 3 patients achieve normal weight, while 8 out of 10 lose some weight. A review of clinical studies involving vertical banded gastroplasty states that while 60 percent of initial excess weight was lost, a large percentage of patients regained the weight within 5 years. After 10 years, only 1 in 10 patients had maintained a 50 percent weight loss. European results of laparoscope-assisted VBG operations indicate that mean weight loss amounted to 63-75 percent of excess weight over 1-3 years.
How Does Vertical Banded Gastroplasty Compare With Other Obesity Surgeries?
In general, band-assisted stomach stapling operations like vertical banded gastroplasty fall between two stools. They are neither as safe and convenient as adjustable gastric banding like Lap-Band, nor as effective for weight reduction as gastric bypass operations, like Roux-en-Y. As a result, surgeons are turning away from vertical banded gastroplasty towards Lap-Band and BPD/DS or Roux-en-Y.
What Are The Advantages Of Vertical Banded Gastroplasty?
The clinical advantages of VBG are a relatively low mortality rate and the relative absence of nutritional deficiencies. As the basic digestive anatomy is left intact, the procedure is reversible, albeit not without risk. In addition, since no anastomosis (re-stitching together of intestines) is involved, there is a lower risk of infection. Unlike after stomach bypass operations, VBG patients do not suffer from dumping syndrome, although this is a mixed blessing, as several clinical trials have shown that gastric bypass leads to greater weight losses, in part because dumping syndrome tends to stop sweet-eating.
What Are The Disadvantages Of Vertical Banded Gastroplasty?
The main drawback of VBG is that it requires a high level of patient compliance with the recommended dietary regime. Highly refined foods and junk foods are often easier for vertical banded gastroplasty patients to manage, while healthy higher-fiber foods tend to pass less easily. Other disadvantages of VBG include vomiting and severe discomfort if food is not chewed thoroughly, or if food is eaten too rapidly. Severe heartburn is another documented side-effect. Also, the operation is not adjustable to suit patient needs, as is Lap-Band.
What Are The Health Risks/Complications Of Vertical Banded Gastroplasty?
Despite its relatively short duration, vertical banded gastroplasty is regarded by surgeons a very serious procedure, and is classified as a “severely dangerous” operation by the American Medical Association (AMA). Approximately one in every hundred patients undergoing VBG die in hospital or within 12 months of the operation.
In addition, roughly 1 in 3 patients experience problems with their gastric staple line, while about 1 in 7 VBG patients need a second operation due to stomal stenosis, which causes nausea and vomiting, or because of severe gastroesophageal reflux after eating. Other health risks after vertical banded gastroplasty include incisional infection, the formation of gallstones and the danger of the gastric band eroding the stomach wall. Laparoscopic VBG operations incur complications such as abscesses, leaks, and fistulas.
Can Vertical Banded Gastroplasty Be Reversed Or Converted To A Gastric Bypass?
Yes. VBG may be reversed or converted to a stomach bypass, but the health risks of reversal and conversion are significantly higher than the original stomach stapling procedure.
Reversal of vertical banded gastroplasty is a serious procedure and will be more complex if a polyurethane band (commonly used in the 80s and 90s) needs to be removed. This is because of the extra scar tissue involved. Reversal aslo involves the removal of the gastric staples and reconnecting the separated sections of the stomach. As a result, bariatric surgeons avoid VBG reversals unless medically necessary.
Vertical banded gastroplasty can be converted to a stomach bypass like Roux-en-Y or Biliopancreatic Diversion or Duodenal Switch. Revisional surgery involves substantially increased health risks, but it can offer significant health and weight loss benefits.
Who Is A Good Candidate For Vertical Banded Gastroplasty?
To qualify for any obesity surgery, patients need to be clinically obese with either a body mass index of 40+, or one of 35+ with a life-threatening weight-related health problem, such as heart disease, obstructive sleep apnea, hypertension, or type 2 diabetes. Alternatively, your obesity should cause significant problems with employment or mobility. However, most obesity clinics and hospital bariatric centers no longer recommend vertical banded gastroplasty, preferring adjustable gastric banding or gastric bypass surgeries.