Obesity Surgery, 10, 409-412 Open vs Laparoscopic Vertical Banded Gastroplasty: A case control study with 1-year follow-up Andrea Dávila-Cervantes, MD1; Gabriella Ganci-Cerrud, MD1; Rosa Gamino, SW1; José Gallegos-Martínez, MD2; Jorge González-Barranco, MD2; Miguel F. Herrera, MD1 1 Department of Surgery. and 2The Obesity Clinic, Instituto Nacional de la Nutrición Salvador Zubirán, Mexico City, Mexico Background: Vertical Banded Gastroplasty (VBG) is one of the most common bariatric operations. It can be performed by open or laparoscopic methods. The purpose of this study was to analyze and compare the 1-year results of 40 patients who underwent laparoscopic (20) and open (20). Methods: The initial 20 patients undergoing Laparoscopic VBG and the initial 20 patients in whom an Open VBG were performed in our Institution were comparatively evaluated. Demography, surgical details, complications, and 1-year weight loss were analyzed. Results: Both groups were highly comparable in terms of age, sex and body mass index. Laparoscopic VBG was a more prolonged procedure (median 4 hr) than the open VBG (median 3 hr). On the other hand, hospital stay was significantly shorter in the laparoscopic procedure (median 10 days for the open and 6 days for the laparoscopic). One year weight loss and complications were similar in both groups. Conclusions: Laparoscopic VBG is a safe procedure for the treatment of morbid obesity. This initial series shows comparable results. Key words: Morbid obesity, bariatric surgery, gastroplasty, laparoscopy defined as a body mass index (BMI) >40 kg/m2 or a weight of 100% or more above the ideal body weight. Morbid Obesity is associated with a high frequency of complications and early mortality. Bariatric surgery is currently the most effective treatment for this group of patients.1 Many bariatric operations have been described since Kremen, Linner and Nelson reported their first jejunoileal bypass in 1954.2,3 Among the operations most frequently used is the vertical banded gastroplasty (VBG): in a series of 14,641 bariatric operations from the International Bariatric Surgery Registry, VBG had been performed in 36.3% of this population with a long-term mean loss of excess body weight of 58%.4 Important advances in endoscopic surgery have made it possible to perform bariatric operations laparoscopically. Laparoscopic VBG was first described by Chua and Mendiola in 1995 and some subsequent reports have been published.5,6 The aim of the present study is to analyze our 1year results in the first 20 patients undergoing laparoscopic VBG and to compare those results with a non-concurrent group of 20 patients who underwent open VBG. Introduction Morbid obesity is a major health problem. It is Patients and Methods Reprint requests to: Miguel F. Herrera, MD, Department of Surgery, Instituto Nacional de la Nutrición Salvador Zubirán, Vasco de Quiroga 15, Tlalpan 14000 México, D.F., MEXICO. Tel: (52-5) 573-1200, x2144; fax: (52-5) 573-9321; E-mail: herreram@quetzal.innsz.mx Twenty morbidly obese patients underwent laparoscopic VBG between July of 1997 and December of 1998. Demography, surgical details, surgical com- © FD-Communications Inc. Obesity Surgery, 10, 2000 409 Dávila-Cervantes et al plications, and 1-year weight loss were analyzed and compared to the initial 20 patients who underwent open VBG in our Institution from 1992 to 1998. Patient selection and preoperative evaluation: A multidisciplinary evaluation was performed on all patients including a complete physical examination, laboratory work-up and a cardiopulmonary evaluation. All were non sweet-eater patients with a BMI between 40 and 50 kg/m2. Surgical technique: VBG was performed through a midline supraumbilical incision following the technique described by Mason in 1982 without calibration of the pouch.7 A 25-mm circular stapler was used to create the window, a TA 90-B linear stapler was selected for the partition, and a 5-cm Marlex mesh collar was placed to restrict the reservoir outlet. Laparoscopic VBG was performed using 5 trocars in the standard position for gastric surgery. A 25-mm circular stapler was used to create the window, a non-cutting 60-mm linear stapler was employed for the partition in 10 patients, and division of the stomach with a 60-mm cutting linear stapler was selected in the last 10 patients. A 5-cm Marlex mesh collar was also placed and fixed around the outlet to restrict the pouch. All patients underwent a postoperative Gastrografin ® upper gastrointestinal (GI) x-ray study. Liquid diet was administered once leaks were ruled out and adequate emptying was confirmed. Minced food was administered from the 3rd postoperative day and maintained for a 6-week period. Patients were followed monthly for 3 months and every 3 months for a year. In all visits, a diet history was taken, patients were weighed and a careful interrogatory looking for complications was carried out. An upper GI contrast series was performed at 1 year after surgery to evaluate the status of the operation. the laparoscopic group, and hospital stay was more prolonged in the open group (Table 2). One patient in the open group developed superficial vein thrombophlebitis. There was one non-operative mortality at 3 months follow-up in the open group due to an unexpected coagulopathy. The remaining patients completed 1-year follow-up. Weight loss was faster during the initial 6 months regardless of the surgical approach. Mean weight loss at this period was 28 kg in the open and 20 kg in the laparoscopic group. Body weight modifications during the 1st year are shown in Figure 1. Excess weight loss at 6 months follow-up was 42% and 44% for the open and the laparoscopic groups respectively. At one-year follow-up, these figures increased up to 57% and 52% respectively (Figure 2). Changes in Table 1. Demography Open Laparoscopic n=20 n=20 Age, years 38 ± 10 32 ± 10 Sex, M:F 3:17 2:18 Preoperative excess weight, % 94 ± 15 92 ± 14 Preoperative BMI kg/m2 45 ± 6 44 ± 6 Table 2. Surgical details and complications Operative time, hours Hospital stay, days Transfusions, n Complications, n Additional procedures Open 3±1 10 ± 6 0 1 5* Laparoscopic 4±1 6±1 0 0 0 *cholecystectomies 120 D 110 Open Laparoscopic Kg 100 90 Results Both groups were highly comparable in terms of age, sex distribution and preoperative weight (Table 1). All patients underwent a satisfactory VBG with no conversions in the laparoscopic group. Mean operative time was slightly longer in 410 Obesity Surgery, 10, 2000 80 70 Pre-op 6 months 1 year Figure 1. Mean Weight. Changes during the first year after surgery. All values are mean ± standard error. Open vs Laparoscopic VBG the BMI are shown in Table 3. The number of Discussion patients who achieved different excess weight loss was also similar in both groups (Table 4). Postoperative Gastrografin® study was normal in all patients. The upper GI contrast study 1 year later showed stomal stenosis in one patient of the open group and partial staple-line disruption in one patient of the laparoscopic group. The stomal stenosis required endoscopic dilatation, and the patient with partial staple-line disruption achieved a 20-kg weight loss at 1-year follow-up with no additional treatment. 11 D Open Laparosocpic 0 % 90 70 50 Pre-op 6 months 1 year a) Excess body weight b) Excess body weight (%) % 6 months Open 42 ± 7 Laparoscopic 57 ± 5 1 year 44 ± 6 52 ± 2 Figure 2. Excess body weight and excess body weight loss during the first year after surgery. All values are mean ± standard error. Table 3. Body mass index BMI kg/m2 Preop 6 months 1 year Open n=19 45 ± 6 34 ± 5 32 ± 5 Laparoscopic n= 20 44 ± 6 38 ± 3 33 ± 5 Table 4. Number of patients at different % of excess weight loss at 1-year follow-up EWL (%) <25 26-50 51-75 >75 Total Open n 3 10 6 0 19 % 16 53 31 0 100 Laparoscopic n % 1 5 11 55 8 40 0 0 20 100 VBG is one of the most frequently performed bariatric operations. It provides satisfactory results in terms of weight loss and has a very low incidence of complications. The introduction and rapid development of laparoscopic techniques has permitted performance of a wide variety of procedures in a safe way. Laparoscopic techniques in general have been demonstrated to produce less trauma, to reduce hospital stay, to diminish postoperative pain, and to improve the early return to full normal activities. 6-9 Reports of laparoscopic bariatric surgery have been consistent with these findings and have shown an additional improvement in postoperative respiratory function.6 Our initial experience has shown that laparoscopic VBG is a relatively simple operation that can be carried out almost identically to the original open technique.7 Considering that the laparoscopic technique does not differ from the open procedure, the same long-term results should be anticipated. However, some technical details need special consideration. The original operation was described with intraoperative calibration of the gastric pouch. Several authors have performed the technique without calibration, obtaining similar results. 10,11 Calibration in the laparoscopic procedures is generally omitted. Although the aim is always to create a very small reservoir, the lack of tridimensional view and palpation might influence the ultimate size of the gastric pouch. A comparative analysis of pouch size using both techniques needs to be evaluated. Several surgical techniques and stapling devices have been used for the construction of the gastric pouch. In the original technique, gastric partition without division was recommended. This can be performed in open surgery using one or two firings of a standard non-cutting lineal stapler or one or two firings of a special bariatric stapler (TA-90B) which gives 4 rows of staples in each application. An endoscopic non-cutting linear stapler was available for a period of time and was used in our initial 10 laparoscopic operations. However, current instrumentation only permits us to perform the operation by dividing the stomach. Obesity Surgery, 10, 2000 411 Dávila-Cervantes et al MacLean and colleagues11 reported in 1993 a modification of VBG consisting of division of the stomach. With this technique the authors reported a higher incidence of gastric fistula. 11-13 This complication was considered as a primary factor contributing to an unsatisfactory outcome and need for reoperation. In the 10 laparoscopic patients of this series in whom the stomach was divided, no gastric fistula was seen. Comparative resistance of the laparoscopic instruments and the frequency of gastric fistula in laparoscopic operations need to be evaluated in a larger number of procedures. At 1-year follow-up, no differences were found in the amount of weight loss with either technique. Partial staple-line disruption was found in only one laparoscopic case and corresponded to the group of patients in whom the non-cutting stapler was used. Results of bariatric operations have two different components: the maximum weight loss achieved and the overall time that patients maintain a reduced weight. This initial series only shows that the amount of weight lost during the 1st year is comparable in both techniques. Weight behavior in the long-term needs further evaluation. Surgical time in our study was longer in the laparoscopic approach. As in most initial reports, laparoscopic techniques take longer operative time. We believe that this only represents our learning curve and should decrease with time. The hospital stay was significantly shorter after laparoscopic VBG, and we believe this is more related to changes in our surgical practice than to the technique itself. Since we take care of patients from several parts of our country and we send them home when they are totally recovered, long postoperative periods are common in our hospital. In our initial practice a Gastrografin® GI x-ray study was performed on the 5th postoperative day and diet was administered afterwards. Currently, we perform our Gastrografin® studies on the day after surgery and send the patients home as soon as they are able to walk and eat minced food. This explains the dramatic changes in postoperative hospital stay. This initial experience shows that laparoscopic VBG compares with the open procedure in terms 412 Obesity Surgery, 10, 2000 of short-term results and complications. Further studies need to be carried out to analyze specific details of both techniques. References 1. National Institutes of Health Consensus Development Conference Draft Statement on Gastrointestinal Surgery for Severe Obesity. Obes Surg 1991;1:25765. 2. Hall JC, Watts JM, O’Brien PE. Gastric Surgery for morbid obesity. The Adelaide Study. Ann Surgery 1990;211:419-27. 3. Linner JH, Drew RL. Why the operation we prefer is the Roux-Y gastric bypass. Obes Surg 1991;1:305-6. 4. Mason E, Shenghui T, Renquist K et al. A decade of change in obesity surgery. Obes Surg 1997;7:189-97. 5. Chua T, Mendiola R. Laparoscopic vertical banded gastroplasty: The Milwaukee Experience. Obes Surg 1995;5:77-80. 6. Lönroth H, Dalenback J, Haglind E et al. Vertical banded gastroplasty by laparoscopic technique in the treatment of morbid obesity. Surg Laparosc Endosc 1996; 6:102-7. 7. Mason EE. Vertical banded gastroplasty for obesity. Arch Surg 1982;117:701-6. 8. Majeed AW, Troy G, Nicholl J et al. Randomized, prospective, single blind comparison of laparoscopic versus small-incision cholecystectomy. Lancet 1996;347:989-94. 9. Hinder R, Filipi C. The technique of laparoscopic Nissen fundoplication. Surg Laparosc Endosc 1992;2:265-73. 10.Deitel M. Update general surgery: morbid obesity. Annals RCPSC 1990;23:241-6. 11.MacLean I, Rhode BM Forse A. A gastroplasty that avoids stapling in continuity. Surgery 1993;113:380-8. 12.Toppino M, Nigra I, Olivieri F et al. Staple-line disruptions in vertical banded gastroplasty related to different stapling techniques. Obes Surg 1994;4:256-61. 13.Melissas J, Christodoulakis M, Schoeretsanitis G et al. Staple-line disruption following vertical banded gastroplasty. Obes Surg 1998;8:15-20. (Received February 28, 2000; accepted August 1, 2000)