About Vertical Gastrectomy (VG)
The Vertical Gastrectomy procedure (also called vertical Sleeve Gastrectomy, Greater Curvature Gastrectomy, Parietal Gastrectomy, Gastric Reduction and even Vertical Gastroplasty) is performed by approximately 15 surgeons worldwide. It was originally conceived of by Dr. Johnston in England (Magenstrasse and Mill operation) and has been further developed and utilized in the United States, Germany and Belgium. It generates weight loss by restricting the amount of food that can be eaten (removal of stomach or vertical gastrectomy) without any bypass of the intestines or malabsorption. The stomach pouch is usually made smaller than the pouch that Duodenal Switch patients have. Critics of this procedure state that while early results look promising, the lack of an intestinal bypass may lead to weight regain. They base their criticism on older data from gastroplasty procedures done in the 1970's and 80's. Basically, it is an improvement over prior gastroplasty procedures, which are rarely done due to problems related to the placement of staples, silastic rings and mesh around the stomach pouch. In addition to avoiding foreign bodies, the other advantage over the older procedures is that the excess stomach volume is removed, not left in place. This possibly eliminates most Ghrelin hormone production and helps to reduce the sensation of hunger that people have. Currently it is approved by some insurance companies, but may be considered investigational by others. A additional discussion based on BMI is below.
Vertical Gastrectomy Patients
High
BMI patients (BMI > 50-60): In America and Germany, this procedure was first performed laparoscopically in very high BMI patients to try to reduce the overall risk of weight loss surgery. Once a patients BMI goes above 60Kg/M2, it is increasingly difficult to perform a Roux en Y gastric bypass or a Duodenal Switch laparoscopically. In addition, a Roux en Y gastric bypass tends to yield inadequate weight loss for patients with a BMI greater than 60Kg/M2. The Duodenal Switch is very effective for high BMI patients but unfortunately it can also be quite risky and may by safer if done open. The Vertical Gastrectomy is a reasonable solution to this problem. It can usually be done laparoscopically in patients weighing over 500 pounds. The stomach restriction that occurs allows these patients to lose more than 100 pounds and in many patients more than 200 pounds. This weight loss allows significant improvement in health and effectively "downstages" a patient to a lower risk group. Once the patients BMI is lower (35-40) they can return to the operating room for the "second stage" of the procedure, which can either be the Duodenal Switch, Roux en Y gastric bypass or even a LapBand. Currently, results of the second stage are very limited.
Low
BMI patients (BMI 35-45 Kg/M2): This procedure was also started in England over 5 years ago as a stand alone weight loss procedure for anyone with a BMI greater than 35 Kg/M2 (Johnston D. Obesity Surg 2003; 13:10-16). It proved to be quite safe and quite effective even at 5 years. 10% of the patients did fail to achieve a BMI below 35 at 5 years and these tended to be the heavier patients. The same ones we would expect to go through a second stage as noted above. Low BMI individuals who should consider this procedure include:
Those who are concerned about the potential long term side effects of an intestinal bypass such as intestinal obstruction, ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency.
Those who are considering a LapBand but are concerned about a foreign body.
Those who have other medical problems that prevent them from having weight loss surgery such as anemia, Crohn's disease, extensive prior surgery, and other complex medical conditions.
People who need to take anti-inflammatory medications may also want to consider this. Usually, these medications need to be avoided after a gastric bypass because the risk of ulcer is higher.
Our experience: We initiated this procedure for our high risk and high BMI patients in 2002. The results have been very impressive. In over 800 patients, there have been no deaths, no conversions to open and a leak rate of < 1% (Our early results were presented at the American College of Surgeons, October 2004: www.facs.org/education/gs2004/gs33lee.pdf).
Vertical Gastrectomy: How it Works
This procedure generates weight loss soley through gastric restriction (reduced stomach volume). The stomach is restricted by dividing it vertically and removing more than 85% of it. This part of the procedure is not reversible. The stomach that remains is shaped like a banana and measures from 1-2 ounces (40-60cc) depending on the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while reducing the volume. By comparison, in a Roux-en-Y gastric bypass, the stomach is divided, not removed, and the pylorus is excluded. The Roux-en-Y gastric bypass stomach can be reconnected (reversed) if necessary. Note that there is no intestinal bypass with this procedure, only stomach reduction.
Advantages of the Vertical Gastrectomy Weight
Loss Surgery
- The stomach is reduced in volume but tends to function normally so most food items can be consumed, albeit in small amounts.
- Eliminates the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin).
- No dumping syndrome because the pylorus is preserved.
- Minimizes the chance of an ulcer occurring.
- By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are almost eliminated.
- Very effective as a first stage procedure for high BMI patients (BMI>55 kg/m2).
- Limited results appear promising as a single stage procedure for low BMI patients (BMI 35-45 kg/m2).
- Appealing option for people with existing anemia, Crohn's disease and numerous other conditions that make them too high risk for intestinal bypass procedures.
- Can be done laparoscopically in patients weighing over 500 pounds.
Disadvantages
of the Vertical Gastrectomy Weight Loss Surgery
- Potential for inadequate weight loss or weight regain. While this is true for all procedures, it is theoretically more possible with procedures that do not have an intestinal bypass.
- Higher BMI patients will most likely need to have a second stage procedure later to help lose the rest of the weight. Two stages may ultimately be safer and more effective than one operation for high BMI patients. This is an active point of discussion for bariatric surgeons.
- Soft calories such as ice cream, milk shakes, etc can be absorbed and may slow weight loss.
- This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur.
- Because the stomach is removed, it is not reversible. It can be converted to almost any other weight loss procedure.
- Considered investigational by some surgeons and insurance companies.
Vertical
Gastrectomy: Risks and Complications
As
with any surgery, there can be complications. This list can include:
- Deep vein thrombophlebitis 0.5%
- Non-fatal pulmonary embolus 0.5%
- Pneumonia 0.2%
- Acute respiratory distress syndrome 0.25%
- Splenectomy 0.5%
- Gastric leak and fistula 1.0%
- Postoperative bleeding 0.5%
- Small bowel obstruction 0.0%
- Death 0.25%
Post-Op Dietary Plan for Vertical Gastrectomy Weight-Loss Surgery Patients
As with all surgical weight-loss programs, it is imperative that VG patients adhere to a strict postoperative diet. Patients must stick to a liquid-based diet for 2 weeks after surgery; 4-6 weeks after the operation, patients graduate to a 600-800 calorie/ day solid diet. Once goal weight is achieved, usually 1-2 years after surgery, most patients can consume about 1000-1200 calories per day.
Long-Term Weight-Loss Results
On average, patients who undergo Vertical Gastrectomy surgery experience 60-80% loss of excess weight.
Consider VG Weight-Loss Surgery
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