Options for restrictive surgery
• Vertical-banded gastroplasty: A stapling device is used to divide the stomach vertically along the lesser curve starting at the angle of His to create a small (20-mL) pouch. A prosthetic nonadjustable device is then wrapped around the outlet of the pouch to prevent it from dilating over time. This operation has fallen out of favor because of poor long-term weight loss and issues with GERD and pouch obstruction, and is no longer performed. This operation is frequently converted to a gastric bypass. The mistake often made is to dilate the outlet of the pouch, but with a fixed band this approach usually does not work.
• Gastric banding: This procedure is performed laparoscopically and involves placement of an adjustable silicone band around the top of the stomach to create a small (15-mL) pouch. The band is connected to a reservoir placed in the subcutaneous tissue that enables band adjustment.
• Sleeve gastrectomy: This procedure is gaining in popularity and involves stapling and removing a majority of the gastric body and fundus, leaving the lesser curvature and a small amount of antrum. The pylorus remains intact. The staple line is usually formed over a bougie sized between 32 and 40 French.