VERGITO: Vertical Gastrectomy, Ileal Transposition, Omentectomy - Metabolic Surgery without Malabsorption

The VERGITO Procedure is a novel operation to treat obesity and its attendant co-morbid conditions. It consists of three components, each of which affects weight loss and metabolism to a certain degree; added together, these components work in concert to achieve weight loss through a combination of dietary restriction and changes in metabolism. No part of the intestines or duodenum is bypassed, which allows absorption of vitamins and nutrients to occur normally. In essence, it allows for a metabolic operation without malabsorption.

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The First Component: Vertical Gastrectomy

The restrictive effect of vertical gastrectomy and how it affects appetite and the overall decrease in food intake is well known. The natural inlet and the natural outlet of the stomach is preserved, but the excess capacity of the left side of the stomach is removed, leaving a 2-3 oz. tubular stomach. Reduction in appetite is accomplished in three ways: reduction in stomach volume, reduction in ghrelin secretion, and accentuation of antral stomach stretching. That the stomach volume is significantly reduced is self evident; the 1 ½ quart size stomach is reduced to a 2-3 oz. tube, restricting how much food can be consumed at a given time. Ghrelin, a hormone which affects appetite, is produced by certain cells in the portion of stomach which is removed, independently reducing hunger and food intake. Stretching of the stomach is another mechanism by which our bodies tell us when to stop eating, and the portion of the stomach that is most sensitive to this stretching - the downstream portion of the stomach known as the antrum - is left intact. In fact, because most of the stomach upstream to the antrum is removed, the antrum stretches sooner and faster than it normally would, resulting in a very strong signal telling your brain that your stomach is full.

The Second Component: Ileal Transposition

In this part of the procedure, a section of the downstream intestine - known as the ileum - is brought up and spliced back into the intestine much further upstream. In doing so, ingested food passes through the downstream intestine - the ileum - much earlier than it otherwise would be. When this occurs, the body reacts to carbohydrate meals much differently. The production of naturally occurring hormones in the intestine - such as GLP-1 or enteroglucagon - is increased, which have the effect of improving insulin resistance, which results in fewer calories being converted into body fat. This occurs despite the fact that the overall length of intestine is not decreased, and ingested food passes through the entire length of intestine. Unlike gastric bypass and duodenal switch, calcium and iron malabsorption do not occur, as these ingested nutrients are allowed to pass through the first part of the small intestine known as the duodenum. This reconfiguration of the intestine also results in decreased absorption of cholesterol, which occurs as a side effect of improved recirculation of bile salts to the liver.

The Third Component: Omentectomy

Omentectomy - removal of the omentum - has the effect of augmenting weight loss through a combination of improving insulin resistance and reducing inflammation. The omentum is the fatty sheet inside the abdomen which drapes over the intestine, and is a major component of organ or "visceral" fat, the type of "belly fat" which is associated with the highest health risk. Removing the omentum not only results in an immediate reduction in belly fat, but in the removal of certain substances produced in the omentum as well, namely, resisten - which contributes to insulin resistance and type II diabetes - and various inflammatory agents known as interleukins. Obesity is, in one sense, an inflammatory condition, and removing the omentum as a source of interleukins reduces the inflammatory response of obesity, especially to the liver during active weight loss. Omentectomy has been added to other weight loss procedures in the past and has been shown to result in better weight loss, when compared to the same procedures performed without omentectomy.

VERGITO: Putting it all Together

The overall effect of VERGITO is that of a restrictive operation accentuated by a metabolic effect. It occupies the gap between the purely restrictive procedures - such as LapBand and Vertical Gastrectomy - and the nutrient-malabsorptive procedures, namely, Gastric Bypass and Duodenal Switch. Because it utilizes a pylorus-preserving stomach pouch and an anti-diabetic effect by re-routing food through the ileum early on in digestion, VERGITO can be likened to a partial duodenal switch, minus the effect of duodenal exclusion and starch/fat malabsorption.

Tracking the course of a typical meal can illustrate how the VERGITO procedure works. Food is eaten, and due to the characteristics of how the stomach is constructed, a broad variety of foods are tolerated, only in diminished amounts. A combination of small stomach volume, accentuated stomach stretching, and ghrelin suppression allows patients to feel full and satisfied after eating only a modest amount of healthy food. The food then passes through the duodenum, where iron and calcium are absorbed normally. Within a foot of passing through the duodenum, the food passes through a segment of ileum, which has been repositioned there by the ileal transposition portion of the procedure. This results in an early and accentuated increase in enteroglucagon into the patients bloodstream, which decreases the patient's insulin and blood sugar levels, resulting in less of the ingested calories being converted into body fat. Bile salts are absorbed earlier on - and in greater amounts - than they normally would be, which reduces cholesterol absorption. The food then passes through the remainder of the intestine, where the absorption of vitamins, minerals, and other nutrients occurs normally.

VERGITO: Risks of the Procedure

Although VERGITO is as of yet a novel and untested procedure, the risks of surgery are expected to compare with those of similar procedures. Those risks include: staple-line leak, infection, bleeding, nausea/vomiting, blood clots in the legs or lungs, and bowel obstruction due to scar tissue or to twisting of the intestine. Other risks are those which are more specific to the underlying health status of the patient undergoing the procedure, such as heart attack, kidney failure, and the possibility of requiring prolonged assistance with a ventilator in order to breathe. Patients undergoing this procedure should understand that - despite how well the individual components of the procedure are understood - it is expected to be considered an experimental procedure. As such, there may be consequences of the procedure that are unexpected, and which might possibly require reversal of the operation. In addition, VERGITO is not expected to be covered by health insurance.

VERGITO: Revisions and beyond

There are two general considerations with VERGITO in revision procedures: revision/conversion of a previous bariatric procedure to VERGITO, and revision of the VERGITO procedure itself.

There are instances where revision/conversion to VERGITO from an existing procedure would be indicated. One situation would be where a patient has had a Vertical Gastrectomy in the past, but whose weight loss or improvement in insulin resistance is inadequate. As an alternative to conversion to Duodenal Switch, conversion to VERGITO can be performed. This conversion is not as an aggressive a procedure as a Duodenal Switch, but can provide a metabolic enhancement to effect further improvement in health. Alternatively, if a patient has had a Duodenal Switch and is suffering from metabolic bone disease that is not responding to maximal therapy and supplements, conversion to VERGITO can maintain some metabolic effect of surgery but eliminate the malabsorptive effect.

For those patients who undergo VERGITO and do not obtain adequate weight loss, revision may be performed by either conversion to Duodenal Switch or by reducing the amount of absorption through the small intestine by the principle of Digestive Adaptation. In a Digestive Adaptation revision, the basic intestinal sequence of VERGITO is preserved, but small intestine just downstream from the ileal transposition segment is removed to shorten the overall intestinal length. The main and unique risk of Digestive Adaptation is reducing the intestinal length too much, resulting in malnutrition via a "short gut syndrome". The absorption through the duodenum, however, remains intact.

For a comparison of the procedures our surgeons offer click here. Please note VERGITO and Vertical/Sleeve Gastrectomy will be added to chart soon.