[1] Vertical Banded Gastroplasty: A Treatment for Morbid Obesity - 1

AORN Journal, Dec, 2000 by Susan Goldberg, Peggy Rivers, Kelly Smith, William Homan

Obesity is the number one health problem in the United States today--greater than cancer, heart disease, AIDS, or asthma.(1) Morbid obesity can lead to diabetes, heart disease, and predisposes sufferers to some cancers (eg, breast, colon, endometrial), back problems, arthritis (especially of the hips and knees), and tremendous medical and social costs.(2) Bariatric medicine involves the care of the obese patient. The term bariatric comes from the Greek barys, meaning heavy, and from the New Latin atria, meaning relating to medical treatment. At our hospital, White Plains Hospital Center (WPHC), White Plains, NY, we have created a program that draws on numerous disciplines, including physical therapists, registered dietitians, psychologists, internists, endocrinologists, and surgeons. This article discusses a surgical procedure known as vertical banded gastroplasty (VBG), one method of treating morbid obesity.

Surgical treatment, while difficult, may be worthwhile for some obese patients. Recent statistics indicate that deaths from obesity, including deaths due to comorbidities, total more than 300,000 per year in the United States.(3) Currently, approximately 55% of American adults and 25% of American children are overweight or obese, and between five and 10 million Americans are morbidly obese.(4) Undergoing this surgical procedure and accepting the permanent postoperative lifestyle changes that accompany it often is a difficult decision that requires support and counseling from the entire bariatric team.

MEDICAL IMPLICATIONS OF OBESITY

Morbid obesity is defined as 100 lbs more than one's ideal weight or a body mass index (BMI) of more than 40. People who suffer from morbid obesity may lead very difficult lives. Often they cannot tie their shoes, sit in chairs, wash themselves, turn over in bed, hold a job, fly on airplanes, or find clothes that fit. They face increased risk of diabetes, hypertension, sleep apnea, congestive heart failure, osteoarthritis, hyperlipidemia, gallbladder disease, and urinary stress incontinence.(5) Obese people often are shunned by society and blamed for having weak characters.(6) Elective surgery may be indefinitely delayed because their many medical problems make them a high surgical risk.(7) Only one person in seven suffering from morbid obesity will live to his or her full life expectancy.(8)

Surgeons are not the only professionals who may try to avoid dealing with these patients. A widespread prejudice exists against obesity. The prevailing notion that "if these people would just stop eating so much" crosses all social, cultural, intellectual, and economic lines. Although overeating and emotional problems often lead to obesity, research indicates that the most important factor is genetics.(9) Researchers have identified an obesity gene in rodents. When the gene was blocked, the animals lost weight. Someday, treating obesity with gene therapy may be an option.(10)

ANATOMY AND PHYSIOLOGY OF THE DIGESTIVE TRACT

Food enters the mouth and travels through the esophagus to the stomach, located in the upper abdomen. The stomach, an organ that can store up to three pints of food at one time, aids digestion by secreting hydrochloric acid. If this acid leaves the stomach, it causes heartburn, pain, ulceration or bleeding to the lining of the esophagus or the duodenum.(11) The upper cardiac orifice, which opens into the esophagus, and the circular pyloric muscle work to keep the acid contained in the stomach.

Sensors in the wall of the duodenum (ie, the portion of the small intestine immediately beyond the stomach) signal the pyloric muscle to relax, allowing food to leave the stomach and empty into the duodenum. In the duodenum, alkaline bile and pancreatic juice help neutralize the stomach contents. These same sensors also prevent further stomach contents from entering the duodenum until the stomach acid is neutralized and diluted.

The duodenum absorbs most of the body's iron and calcium, and the digestion of meat and protein by the pancreatic enzymes begins here. Food then moves into the small intestine where most of the absorption of digested food occurs. As the large bowel collects the residue remaining from the digested food, most of the fluid already has been absorbed. The colon absorbs any water remaining in the residue and forms and saves solid feces for elimination (Figure 1).

[Figure 1 ILLUSTRATION OMITTED]

COMMON SURGICAL PROCEDURES

Vertical banded gastroplasty is one of the two most commonly performed procedures for weight loss. The other is the gastric bypass, also known as the Roux-en-Y.(12)

Gastric bypass. During the gastric bypass procedure, a small horizontally or vertically oriented pouch is made in the stomach, and a bypass of most of the stomach and a varying amount of the small intestine is performed. This is accomplished by an anastomosis to reroute digested food from the new pouch to the small bowel (Figure 2). The procedure lasts approximately two hours. Weight loss is accomplished both by restriction of food quantity and malabsorption of nutrients. Anemia due to poor absorption of iron and vitamin [B.sub.12] is common after this procedure unless the patient takes vitamin and iron supplements. In addition, poor absorption of calcium may be a particular problem in women and can result in osteoporosis. After this procedure, staples at the top of the stomach completely block off the lower portion of the stomach and the upper small intestine. This makes it impossible to evaluate these portions of the gastrointestinal (GI) tract should a problem (eg, ulcer, bile duct stones, cancer) arise in the future. Patients who undergo Roux-en-Y surgery commonly experience somewhat greater weight loss than patients undergoing VBG, however in our opinion, the potential problems of malabsorption, increased chance of serious complications, and inability to evaluate the GI tract can outweigh this benefit.