Chapter 33

The vertical banded gastroplasty (VBG) was first described by Mason in 1982.1 It is a restrictive procedure that consists of a vertically oriented proximal small pouch (less than 30 mL) that drains through a narrow (10–12 mm) gastric channel. The outlet channel is reinforced with a band of polypropylene (Marlex) mesh, PTFE (Gore-tex), or a silastic ring. The 1991 NIH Consensus Conference for the treatment of morbid obesity endorsed both the Roux-en-Y gastric bypass (RYGBP) and VBG.2 Although VBG was commonly performed in the 1980s and 1990s for the treatment of morbid obesity,3 it has largely been abandoned in the United States due to poor long-term results.4 The VBG was still mentioned as an option in the 2004 ASBS Consensus Conference Statement5; however, in February 2006, the US Department of Health and Human Services Centers for Medicare and Medicaid Services announced “that the evidence [for VBG] is not adequate to conclude that it is reasonable and necessary; therefore, it is non-covered for all Medicare beneficiaries”6; other private insurers in the United States may follow suit.

Balsinger et al. reported the Mayo clinic 10 year results after VBG and demonstrated a 79% failure rate.7 Failure after VBG is most commonly due to poor long-term weight loss, which can result from staple-line dehiscence or from maladaptive diet behavior.7,8 A shortcoming of purely restrictive operations is that bulky solid meals are limited, and patients have a tendency to adopt a high-calorie liquid diet which can pass rapidly through the stoma, leading to regain of weight. Only 26% of the patients in the Mayo study have maintained a weight loss of at least 50% of their excess body weight at 10 years. Other complications that commonly occur after VBG that may require reoperation include stomal obstruction, persistent vomiting, solid food intolerance, pouch dilatation, gastroesophageal reflux disease, aspiration pneumonia, and erosion of the prosthetic band.9

Reoperation rates reported in larger VBG series range from 6% to 44%. Although revision of VBG to VBG has been reported,9,12 almost all of the bariatric surgical literature supports the conversion to RYGBP as the operation of choice after failed restrictive procedures.16–19 Multiple studies have demonstrated that RYGBP has a weight loss success rate superior to that seen in VBG.20–26 VBG is also not as effective as gastric bypass for control of type 2 diabetes mellitus. Several studies have reported conversions of VBG to RYGBP via an open technique, with results of improved weight loss, comorbidities, and correction of complications. There are several reports of laparoscopic revision of VBG to RYGBP. Though feasible, revisional bariatric surgery is technically complicated, whether performed open or laparoscopic, and has a higher complication rate than primary bariatric surgery.40

Revision of VBG to RYGBP should be considered if a patient has any of the following ...

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