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LRYGB vs Laparoscopic Vertical Banded Gastroplasty
Abstract & Commentary
By Namir Katkhouda, MD, FACS, Professor of Surgery, Chief, Minimally Invasive Surgery, University of Southern California (USC)-Los Angeles, CA. Dr. Katkhouda is a consultant for Baxter, Ethicon, Storz, and Gore.
Synopsis: The patient's eating habits before surgery play an important role in the choice of the operative technique used.
Source: Goergen M, et al. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty: Results of a 2-year follow-up study. Surg Endosc. 2007;21:659-664.
Background: the world's epidemic of obesity is responsible for the development of bariatric surgery in recent decades. The number of gastrointestinal surgeries performed annually for severe obesity (BMI > 40 kg/m2) in the United States has increased from about 16,000 in the early 1990s to about 103,000 in 2003. The surgical techniques can be classified as restrictive, malabsorptive, or mixed procedures. This article presents the results for 2 years of bariatric surgery in Goergen and colleagues' minimally invasive center, and analyzes the results of the most used surgical techniques with regard to eating habits.
Methods: Between January 2002 and January 2004, Goergen et al attempted operations for morbid obesity in 110 consecutive patients adequately selected by a multidisciplinary obesity unit. This represented 43% of all consultations for morbidly obese patients. The patients were classified as sweet eaters or non-sweet eaters. All sweet eaters underwent gastric bypass. The procedures included 70 Roux-en-Y gastric bypasses, 39 Mason's vertical banded gastroplasties, and one combination of vertical gastroplasty with an antireflux procedure. Revision procedures were excluded.
Results: The mean age of the patients was 41.36 years (range, 23-67 years), and 72.3% were female. The mean preoperative body mass index was 44.78 kg/m2 (range, 34.75-70.16 kg/m2). The mean operating time was longer for gastric bypass than for the Mason procedure. Three patients required conversion to an open procedure (2.7%). The 2 operative techniques had the same efficacy in weight reduction. Early complications developed in 11 patients (10%), and late complications occurred in 9 patients (8.1%). The postoperative length of hospital stay averaged 4.4 days (range, 1-47 days; median, 4 days) and was longer in the gastric bypass group. The mortality rate was zero. Data were available 2 years after surgery for 101 of the 110 patients (91%). Most comorbid conditions resolved by one year after surgery, regardless of the type of operation used.
Conclusion: With zero mortality and low morbidity, bariatric surgery performed for adequately-selected patients is the most effective therapeutic intervention for weight loss, as well as subsequent amelioration or resolution of comorbidities. The patient's eating habits before surgery play an important role in the choice of the operative technique used.
This study by Goergen et al is very interesting, as it compares the laparoscopic gastric bypass versus vertical banded gastroplasty. It shows that both techniques, in good hands, yield good results. The part that is original is that sweet eaters, identified carefully according to defined criteria, were given the laparoscopic gastric bypass while non-sweet eaters were chosen for the vertical banded gastroplasty. The reason for this distinction is that patients who are sweet eaters who underwent a laparoscopic gastric bypass will present with dumping syndrome in the event of a sweet meal, whereas it would not be an issue for the non-sweet eaters to get a purely restrictive operation.
These results can be extrapolated to the lap band and the sleeve gastrectomy, both restrictive procedures. There is no other study in the literature that compares the 3 operations based on the eating habits. It might be very worthwhile to do, as the restrictive procedures do not produce the same good results in terms of weight loss and resolution of type 2 diabetes. Are we maybe offering the wrong operation to the wrong patient?
A big eater logically should do better than a sweet eater with a restrictive procedure. Opponents to these theories will say that it is very difficult to categorize the eating patterns of the morbidly obese, and most patients have hybrid eating habits.
At the launch of the lap band, surgeons were taught that one should avoid the placement of this device on sweet eaters. With the current enthusiasm for this procedure, we tend to forget this initial warning.