Restrictive procedures (reduction of stomach volume)
Towards the end of the 70s the enteral shunt was abandoned for restrictive procedures in various forms (see Scopinaro) due to extreme complications caused by it. The restrictive procedures consist of stomach volume reduction techniques, which also cause a delayed passage of chyme into the remaining stomach in addition to reduced fill capacities, thus drastically reducing meal sizes. These techniques were inspired by the observation that subsequent to incomplete gastrectomies (partial stomach removal with small remaining stomach) resulted in significant weight-losses after surgery.
Gastroplasty
The idea of gastroplasty (reshaping of the stomach) originates in the concept of the stomach bypass. The idea was to find a simple technique to reduce food ingestion. Since the end of the 70s it has been applied on a broad scale around the world. It was introduced by Alden (Minneapolis, 1976), who reapportioned the stomach using a linear stapler (straight mechanical double suture) thus achieving a simplification of the process and saving time.
Vertical gastroplasty (VGP, fig. 5)
The significant step towards vertical gastroplasty was defined by the way in which the stomach volume was reduced, since the separation was performed along the longitudinal axis – and no longer diagonally, thus, since there is no complete transection of the stomach and continuity is conserved, no connection to the small bowel (gastrojejunostomy, e.g. Roux-Y) was necessary. The attempt to reduce stomach volume by means of an incomplete horizontal mechanical suture separation to create the desired small fundic pouch for restriction of food ingestion failed. The VGP was finally modified by Mason by an augmentation of the pouch exit by means of attaching a band, thus preventing extension in the course of time. An antecedent punching of the stomach by means of a circular stapler actually made the implementation of net- or ring augmentation possible (Fig. 5), along with the fact that it meant an improvement in regard to the application of linear staplers.
- Abb. 5:Vertical gastroplasty
according to Mason
Currently the vertical and band-augmented gastroplasty is still a very common adiposity surgery and distinguishes itself through a very low lethality rate (>0.3%) and an efficient weight loss, which means it comes a close second to stomach bypass surgery. The treatment failure rate is about 10-15%. This may be caused by a successive extension of the proximal stomach reservoir, a rupture of the mechanical suture at the pouch (bursting of the separated stomach into the main stomach) extension of the enteral opening (often in techniques lacking band-augmentation), or circumvention of the general food restriction by frequent ingestion of small but highly caloric meals. Possible complications include obstructions or extensions of the enteral opening, which require further surgeries.