Chirurgie-Digestive.com Docteur Paul Lachowsky
 
Surgery of the Digestif Tract
Surgery of Obesity
Laparoscopy

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Edith Cavell street
32 1180-Brussels
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Obesity Surgery > The Gastroplasty (Gastric Band or Gastric Stapling)

 THE GASTROPLASTY

                                -   1°) with a vertical stapleline

                        -  2°) with gastric banding

The objective is to reduce the volume of ingested food. The normal digestive tract (stomach-duodenum-small intestine- large intestine) is unchanged. This intervention reduces the stomach volume to a small reservoir. Once this filled, whwich happens fast, the pateint will feel not hungry anymore and will restrain from further collation

 - 1°) Gastroplasty by vertical stapleling


gastroplastie verticale

click on picture to enlarge
(Picture traduction : vertical gastroplasty - adjustabel silicon band)

 
A reservoir of 40 ml is created by placing 4 lines of staples with a special clamp vertically on the stomach. A stoma of 12 mm for passage is kept under control by a flexible silicone ring on this level.
This intervention is performed under general anaethesia and takes around one hour. An incission of 7 cm under the sternum is performed.


- 2°) Gastroplasty with gastric band by laparoscopy

 

anneau ajustable avec tuyau siliconé

(Picture translation : Adjustabel silicon band)

radiographie: réservoir de taille normale
Click to enlarge


The adjustable gastric  band is placed arond the superoir parts of the stomach, deviding it in two parts as a sandwatch, with the superior part holding a capacity of approx. 20ml

It exsist out of three parts (see picture below):

- The silicon ring with a adjustable balloon
- The injection port made our of titanium (port-a-cath) placed subcutaneously (an incission of 3 cm is needed for this, see picture)
- A thin silicone tube connecting both parts
Injecting the fluid in the port-a-cath will inflate the balloon that will reduce the stoma size and thus the passage to the stomach.

The advantages of this technique are multiple:

- The band is placed laparoscopically: using a small camera and special instruments avoiding to opne the abdominal wall preventing painfull  and unesthetical surgical incissions. The intervention takes in average 1 hour. Hospitalisation is very short: mostly after two days, or the day after surgery you can leave the hospital.
- Adjusting the band is easy and adapted to each case, allowing a harmonious and slow steady weight loss without any nutritional deficienties;
- The first four weeks only liquid nutrition is advised. At the end of this period a first adjustment can be done, a two-week period of minced nutrition can be started subsequently. A second adjustment will be done wherafter solids can be taken on. One or more adjustments can be done later during routine check-ups

Resuming

- Minimal or non-painful technique
- Respecting esthethics
- Harmonious weightloss with no nutritional deficienties
- Individual adjustable weightloss
- Totaly reversible
- Rapid return to normal activities
- Remarcable nutritional tolerance due to adjuatability of the band

- 3°) Gastroplasty: results and implications for the patient

- Any type of gastroplasty will change the nutritional habits of the patient. It is required to eat slowly, in a calm environment, chewing long and well all solid nutrients. It is imperatieve to stop eating when feeling sasieted. not following these guidelines (eating fast, big volumes) will lead to pain and vomiting blood.
- The new stomach will be full at an equivallent of three spoons of food.
- Only drink between the meals
- Keeping on a diet is recommended. In fact drinking coca-cola or eating ice cream will make you increase in weight regardless of the gastroplastie. Keep on a balanced nutrition. Some nutrients do pass more difficultly then others (e.g. White bread, white meat, red meat, barbecue) however this is case by case different. an own experince will be in place.
- Regular surgical post-operative follow-up is required till stabilisation of the weight.
- Pregnancy in the weightloss phase of a& gastroplasty with stapling of the stomach is contra-indicated for nutritional deficienties, however can be done with gastric banding (the band can be deflated completely)
- Nutritional deficienties are seldom and benign (esp. With gastric banding) and can be corrected with supplements of iron and vitames if necessary.

In average a weightloss of 4 kg per week can be obtained (after a slow start of a couple of days to 3-4 weeks), weight stabilisation will occur from 12 to 16 months on.

The mean weight loss is equivalent to an excess weight loss of 70% after 12 to 16 months and shoud maintain between 50 and 60% after 5 years.

- 4°) Gastroplasty: reasons of failure on the long term


Vertical stapling gastroplasty: gradual weight regain and of fast sasietion sense. In average seen in  more than30 % of the cases over 10 years.


Two most important causes: dishention of the stapleline (gastro-gastric fistula) with quicker passage of nutrients from the small stomach to the larger stomach bypassing the silicone ring.

fistule gastrogastrique

Click to enlarge

- Dilatation of the small reservoir allowing larger volume. Sometimes combined with an erosion of the band in the stomach wall and stenosis of the stoma.

migration de l'anneau dans l'estomac

Click to enlarge

Treatment can consist out of replacing a new stapleling with silicone ring (picture 1)  showing good long term results or adjustable banding (picture 2) by laparoscopy. Gastric byapss procedure seems to be the procedure with the best results so far.

Picture 1                                                 Picture 2 
  réagrafage verticalanneau ajustable après agrafage vertical
Click to enlarge

- Gastroplasty with adjustable gastric banding: weightregain due to pouch dilatation (10% of the cases after 5 years) picture 3 or a partial migartion of the band through the stomachwall (2% of the cases after 5 years) (picture 4)

                      Picture 3                                                                          Picture 4                         

dilatation modérée de la poche gastrique  gastroscopie: migration intra-gastrique de l'anneau
Click to enlarge
(Picture translation : Moderate dilatation of the pouch seen on gastroscopie: intra-gastric migration of the band)

- Major difficulty to keep up feeding due to pouch tilting (in 17% of the cases after 5 years)

Picture 5

dilatation et bascule de la poche

Click to enlarge
(Picture translation : Dilatation en tilting of the pouch)

Treatment of pouch dilatation consists out of correctly replacing the band by laparoscopy making the badn well tolerated and efficient again.

A band erosion (rare complicdation) necessitates the complete removal of the band by laparoscopy. A gastric bypass can eventually be porposed subsequently.

The best prevention of both complications is a regular follow-up with band adjustement



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