Vertical banded gastroplasty versus standard or distal Roux-en-Y gastric bypass based on specific selection criteria in the morbidly obese: Preliminary results

Background: Predicting successful outcomes after bariatric surgical procedu res has been difficult, and the establishment of specific selection criteri a has been a subject of ongoing research. In an effort to choose the most a ppropriate surgical procedure for each patient, we have established a speci fic set of selection criteria for each procedure based on degree of obesity , preoperative dietary habits, eating behavior, and various metabolic featu res. Methods: From June 1994 to December 1998, 90 bariatric surgical procedures were performed at the authors' institution by a single surgeon (F.K.) based on specific selection criteria. Vertical banded gastroplasty (VBG) was per formed in 35 patients, standard Roux-en-Y gastric bypass (RYGB) in 38 patie nts, and distal RYGB in 17 patients. All patients were monitored postoperat ively 1, 3, 6, and 12 months and once per year thereafter, with an addition al visit at 18 months in distal RYGB patients. Results: Early postoperative morbidity (<30 days) did not differ significan tly between the three groups and averaged 9% of total patients. Long-term p ostoperative morbidity (>30 days) included 9 incisional hernias (2 in the V BG group, 5 after RYGB, and 2 in the distal RYGB group). There were 6 cases of staple-line disruption, 4 after VBG and 2 after standard RYGB, 1 of whi ch resulted in stomal ulcer. Early postoperative mortality was 0%, and long -term mortality was 1.1%, which was due to pulmonary embolism in 1 standard RYGB patient on the 65th postoperative day. Average percentage of excess w eight loss (%EWL) was 62% the first year, 61% the second year, and 50% the third year in VBG patients, and 63.6%, 65%, and 63.3%, respectively, in sta ndard RYGB patients. In distal RYGB patients, where the patient number was significantly smaller, the %EWL at 1 and 2 years, respectively, was 51% and 53%. The most significant metabolic/nutritional complication was the appea rance of hypoproteinemia (hypoalbuminemia) in 1 distal RYGB patient 20 mont hs after surgery, which was corrected by total parenteral nutrition and sub sequent increase in dietary protein intake. Significant improvement or reso lution of preexisting comorbid conditions was observed in all patient group s. The postoperative quality of eating, as evaluated by variety of food int ake and frequency of vomiting, was significantly better in RYGB patients. Conclusions: These results show that selection of the bariatric surgical pr ocedure to be performed in each patient based on specific criteria leads to acceptable weight loss, improvement in preexisting comorbid conditions, an d a high degree of patient satisfaction in most patients. On the basis of o ur own observations as well as those of others, our selection criteria have become more strict over time and our selection of VBG as the operation of choice increasingly infrequent.