Chapter 11

Gastroplasty was designed to restrict food intake without introducing bypass complications. It began in 1971 with horizontal gastroplasty and was changed to vertical in 1980, independently by many surgeons. The history helps explain what can cause success or failure. Small changes in design and technique too often lead to failure. Patients need to understand how to take care of their diminutive pouch in order to succeed. Overflow is a normal consequence of improper eating, but uncontrolled vomiting is abnormal and must be corrected before thiamine deficiency causes permanent injury or death (Wernicke–Korsakoff syndrome). Restriction operations are as effective as bypass operations in keeping patients alive for at least the first 8.3 years studied. Lifelong data may be needed to determine the best match of patients to operation type. Vertical pouches preserve the normal anatomy, which is important for preventing esophageal reflux. The ≤20 mL pouch size for gastroplasty is too small for an operation that bypasses most of the small bowel. The pouch outlet for restriction operations is also too small for adding extensive small-bowel bypass in order to increase weight loss. Attempts to increase weight control by decreasing the pouch outlet below that recommended will lead to complications. Revision of vertical pouches that were too large initially and have enlarged to cause progressive increase in vomiting and weight gain should be revised to ≤20 mL, which will correct both complaints. Conversion to a bypass operation is not indicated for these complaints. Operative technique is important in determining whether the pouch is antireflux or causes reflux.

Dietary restriction of intake is the oldest and the least effective treatment for obesity. Surgery for obesity uses (1) restriction, (2) malabsorption, and (3) manipulation of neurohumoral mechanisms for weight control. Gastric bypass for obesity was introduced in 1967 to restrict intake while avoiding the complications of intestinal bypass.1 In 1971 horizontal gastroplasty was introduced as a means of eliminating the complications of gastric bypass, while maintaining the intake deficiency created by a small stomach pouch.2 This was unsatisfactory because pouches were not measured and outlets were not stabilized. In addition, mobilization of the greater curvature brought the stomach into view for horizontal stapling, but when the fundus returned to its original position, the staple-line was slanted upward and emptying was like a cascade. This predisposed to obstruction, especially if the outlet was stabilized with a band that became adherent to adjacent tissues. Obstruction required endoscopy, which was difficult with the outlet high on the greater curvature. We needed a straight shot, which meant an outlet on the lesser curvature.

Beginning in 1980–81 pouches were changed from horizontal to vertical and moved to the lesser curvature to facilitate endoscopy. Michael Long described moving the pouch outlet to the lesser curvature and then, in successive patients, changing the slope of the staple-line from horizontal until it was vertical.3 At the University of Iowa, a stapled circular window was made near the lesser curvature ...

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