What Is Stomach Stapling?
In bariatric medicine, Stomach stapling (AKA gastric stapling or gastroplasty) is a surgical technique which uses gastric staples to reduce the size of the stomach. The technique derives from abdominal stapling methods developed by Soviet surgeons during World War 2. In the 1970s, the high failure rate of the jejunal-ileal bypass and the invention of mechanical staplers led to the development of “restrictive” obesity surgeries such as “horizontal gastroplasty”, which in turn led to vertical banded gastroplasty – the most successful type of gastric stapling surgery. VBG was pioneered by Dr. Mason at the University of Iowa in 1980.
How Is Stomach Stapling Used In Bariatric Surgery?
Obesity surgery may be divided into three types: restrictive surgery, malabsorptive surgery, and a combination type involving both restriction and malabsorption. Gastric stapling is a technique which surgeons use in both restrictive and combined methods to divide the stomach into two segments: a tiny pouch (in effect the new stomach) connected by a passageway (stoma) to the remaining larger part of the old stomach. The new small stomach is roughly the size of an egg, compared to its original melon size, and can accomodate only 1-2 tablespoons of solid food.
How Is Stomach Stapling Used in Restrictive Operations?
Restrictive bariatric surgeries are designed to help patients lose weight by limiting the quantity of food that can be eaten at a single sitting, and by extending the feeling of satiety brought on by a full stomach. Common types of restrictive surgery are vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB). Both types involve a reduction in the size of the stomach, but while VBG involves the use of stomach staples as well as a band to achieve this stomach reduction, AGB only utilizes an inflatable silicone elastomer ring (the gastric band).
What Is Vertical Banded Gastroplasty?
VBG is a mixture of stomach stapling and banding. A 2.5 inch section of less stretchy stomach wall is stapled vertically to create a small stomach pouch. A narrow half-inch gap in the staple line is left as an outlet or exit passageway to allow food to pass very slowly into the large remaining part of the stomach. To prevent this passageway from expanding, the bariatric surgeon places a collar around the outside. The use of a band to maintain the narrow diameter of the stoma is one of the key differences between vertical banded gastroplasty and the earlier, less effective horizontal gastroplasty.
Why Is Vertical Banded Gastroplasty Becoming Less Popular?
There are two basic drawbacks with stomach stapling. First, the stomach is designed to stretch, in order to accomodate relatively large amounts of solid food. This stretchiness can lead to a widening of the passageway exit from the stomach pouch, undermining the point of the operation by permitting a greater intake of food and calories. The second drawback is the possible failure of part or all of the staple line (dehiscence), leading to a similar outcome, and/or a rarer risk of anastomotic leakage which requires urgent hospitalization. Anastomotic leaks occur in fewer than 1 in 50 VBG patients. In summary, the use of gastric stapling techniques in a restrictive bariatric procedure like VBG, make the operation less flexible than adjustable gastric banding, and less effective for weight loss than stomach bypass.
Is Stomach Stapling Used in Restrictive/Malabsorptive Operations?
Yes, but first it’s important to know what’s involved in these bariatric procedures. A combined restrictive/malabsorptive operation aims to accomplish two things. First, like restrictive procedures, it restricts calorie intake by reducing the size of the stomach, as described above. In addition, it reduces the body’s capacity to metabolize and absorb the food that is eaten, by taking food directly from the small stomach pouch to the lower (distal) segment of the small intestine, thus bypassing the remaining part of the stomach, the duodenum and most of the jejunum. As a result, food is unable to mix with the normal amount of digestive enzymes, and its nutrients and calories have less opportunity to be absorbed through the intestinal walls. This extra malabsorptive element further reduces calorie intake, which is why gastric bypass patients tend to lose more weight than patients who undergo purely restrictive surgeries like stomach banding or stapling.
Gastric bypass procedures use a variety of methods to section the stomach and create a small pouch. In Biliopancreatic Diversion (BPD), Duodenal Switch (BPD-DS) and Sleeve Gastrectomy, a large section of stomach is actually surgically removed (gastrectomy), the pouch itself being stapled. The Fobi Pouch bypass involves the use of a silastic ring. While Roux-en-Y gastric bypass (RYGBP) uses stomach staples, or occasionally a gastric band. The use of stomach stapling in restrictive/malasorptive operations like RYGBP and Biliuopancreatic Diversion causes fewer problems than when used in vertical banded gastroplasty because there is no gap in the staple line leading to the rest of the stomach. Instead, food is taken directly from the pouch to the lower small intestine.
What Are The Benefits and Risks of Stomach Stapling?
Gastric stapling used in vertical banded gastroplasty is a more secure method of sectioning the stomach to create a reduced gastric reservoir, than gastric banding. On the other hand, it is less flexible and cannot be adjusted to meet varying calorie needs (eg. during illness). Also, while stomach stapling is more secure than banding, it involves a degree of cutting as well as the implantation of gastric staples, which makes the operation less easily reversed than Lap-Band. Lastly, staple line failure (dehiscence) and anastomotic leakages are possible health complications which make vertical banded gastroplasty less safe than banding procedures like Lap-Band. Some of these health complications are reduced when stomach stapling is used in Roux-en-Y gastric bypass operations.
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