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Laparoscopic Gastric Banding

Morbid obesity is a serious and increasing health problem in North America. All estimates indicate that the obesity epidemic is real and increasing. More younger adults and children have obesity and there is no real treatment in sight. Despite medical therapy, behavior alterations and psychotherapy treatments, this has made no dent in the numbers of obese individuals. Almost every Western country is grappling with the increasing health care costs of treating obesity related complications.

What are surgical treatments for obesity?

There are three general types of bariatric surgery for obesity: restrictive, malabsorptive, and combined restrictive and malabsorptive. Restrictive (Limiting intake or altering digestion) Restrictive procedures have been designed to make the stomach small and hence create a sensation of a full stomach after ingestion of a small amount of food. These procedure have been around for decades and every year another version of the procedure has been created (anytime newer versions of the same thing come up in medicine, means they are either not effective or associated with complications). Gastric banding Gastric banding involves no suturing, stapling or cutting of the stomach; rather a strip of plastic band is placed around the upper part of the stomach to limit entry of food into the stomach. The band limits the food entry and also causes very slow emptying of the stomach. Because of the constant sensation of fullness, individuals then tend to eat less. Individuals who undergo gastric banding can expect to lose up to 60 pounds or more in one year. The duration of weight loss and number of pounds lost, however, is variable. Malabsorptive procedures Malabsorptive procedures alter and divert the digestion process, thus causing food to be poorly digested, incompletely absorbed and the majority is excreted in the stool. There are numerous surgical procedures developed to create malabsorption of food. The stomach is not removed but is bypassed using various surgical techniques. Malabsorptive bypass procedures in general produce more weight loss than restrictive operations and are more effective in reversing the health problems associated with severe obesity. Patients who have malabsorptive operations generally can lose > 75-150 pounds within 1-2 years. The weight loss generally continues for 1¨ö years before stabilizing. Unlike older bypass procedures that involve removal of the stomach, current procedures pose fewer operative risks. However, in comparison to the other weight loss procedure, malabsorptive procedure are not only technically difficult but associated with numerous complications- many of which can be life threatening.

What advances have been made in weight loss surgery procedures?

Older weight loss surgery procedures required a long incisions followed by a prolonged recovery which was about 4-6 weeks. Today, minimally invasive surgical techniques are available that enable physicians to perform both restrictive and malabsorptive bariatric procedures without making big incisions in the abdomen. The minimally invasive approach achieves results comparable to those associated with open surgery, but with less post-operative pain and rapid recovery. Patients who undergo minimally invasive bariatric surgery can expect to return to work 1-2 weeks after undergoing surgery.

What is laparoscopic gastric banding?

Gastric banding is a surgical procedure which basically involves placing an inflatable silicon band around the upper part of the stomach. A reservoir is also placed under the abdominal skin and is used to inflate the balloon and adjust the gastric band. When the band is inflated, the gastric band tightens and decreases the upper part of the stomach- which ultimately decreases the amount of food passing through. When the balloon is deflated, the band deflates and loosens and the stomach regains its original shape and size. The gastric band slows the emptying of this pouch, prolonging this effect. Weight reduction occurs because the food remains in the stomach for a prolonged time creating a sensation of fullness and a lack of desire to eat.

What is body mass index (bmi)?

Body Mass Index (bmi): Body weight (kg)/ height2 (m). If your bmi is: 18.5 - 24.9 you are normal 25 - 29.9 you are considered mildly obese 30 - 34.9 you are moderately obese 35 - 39.9 you are morbidly obese Extreme Obesity (Morbid Obesity): ¡Ã 40, Super obesity: > 50.

Which obese individual should be considered for surgery?

- Patients who have failed drug therapy - Patients who have tried other non surgical methods to lose weight and failed - Patients who have a BMI in excess of 40 kg/m2 - Patients with a BMI between 35 and 40 kg/m2 along with more than one high-risk co-morbid condition, such as severe diabetes, or poor function.

What preparation is required prior to surgery?

Before gastric banding, extensive medical and psychological testing is done to determine if you meet the guidelines and are a good candidate for successful weight loss surgery. Pre-operative testing usually includes: - some routine blood work - a x ray study of your upper stomach and swallowing tube (Upper GI) - ECG - Psychiatric evaluation

What does laparoscopic gastric banding involve?

Gastric banding is always done in a hospital and requires general anesthesia. After the anesthesia is induced, a tube is placed via the nose into the stomach. The surgery is then done using five very small holes in the abdomen, through which are placed the essential instruments and a camera. The entire surgery is done through these small holes and an inflatable band is placed around the stomach. The adjustable elastic band is placed around the upper stomach to create a small 15cc (one half ounce) pouch with a narrowed outlet. The inflating and deflating device is then secured just below the skin above the belly button. The band is left deflated at the end of the procedure.

What happens soon after surgery?

After the surgery, you will be allowed to recover in the recovery room for a few hours. Most individuals have minimal pain. You will not be allowed to eat for the first 24 hours and an intravenous will be started to give you fluids. The following day, an x ray with a dye is done to ensure that the surgery is fine and no damage to the stomach or esophagus has occurred. If everything is fine, you will be allowed to drink some fluids and eat.

When do I go home?

After the first day, you will be encouraged to start walking and take in fluids. For those who have minimal pain and are able to take fluids, discharge is done on the 2nd or 3rd day after surgery

When is the band inflated?

After surgery, you will be allowed to recover for 1-2 weeks. When all the incisions have healed, you will be seen in the weight loss clinic and taken to the radiology department. The small pocket with the plastic cup placed underneath your skin will be filled with water or saline. The band will be inflated under X ray to determine exactly how much tightening is required.

Will I be seen again by the surgeon?

Yes, you will have period clinic appointments to ensure that you are losing weight and that there are no complications

Is any part of my stomach cut or removed?

No, in laparoscopic gastric banding, no part of the stomach or any other organ is cut or removed

What risks are associated with the procedure?

Like any surgery, complications can occur with the procedure. However, most laparoscopic surgeons are very adept at this new technique and serious complications are rare. Complications which may occur include: 1. damage to the abdominal organs during placement of the instruments 2. bowel injury may occur with the instruments 3. bleeding may occur but this is usually identified at the time of the surgery 4. infection 5. Have to convert this to an open surgical procedure (this does happen in 1-3% of cases). This is most common in individuals who have had prior abdominal surgery and the surgeon is unable to insert his instruments safely 6. Perforation of the esophagus or stomach. Both of these are serious and if not identified early, serious complications can occur- which require surgery 7. Migration of band. Even though the band is secured on to the stomach, it can slip and make the surgery completely ineffective.

What are advantages of gastric banding?

When the procedure is successful, the following can occur: - Once the weight loss occurs, control of diabetes improves - Most individuals start to show a decrease in the blood cholesterol - The control of blood pressure improves - On average there is loss of 20-50% of the weight - The procedure can be reversed - There is no cutting of any organs - The gastric pouch can be adjusted giving time for adjustment - Lowest death rate compared to other weight loss procedures - Lowest risk of malnutrition

What are disadvantages of laparoscopic banding?

- weight is slower than gastric bypass - there is risk of slippage of the band around the stomach to an abnormal position - the band can erode into the stomach - the port may malfunction - the band may malfunction - one can still eat high calorie food Some or all of these disadvantages occur in 10-22% of patients, and about 10% of individuals require another surgery to correct the condition. The laparoscopic gastric banding is not a permanent procedure and does require either removal or replacement in the future. Best estimates indicate that at least 40% of patients undergoing this procedure lose less than half their excess body weight.

Can one eat all food after laparoscopic gastric banding?

There are some foods which may not be tolerated and these include? - meat products like steaks - skins of fruits - fruits with seeds - high fiber foods such as celery - very spicy and oily food

When is Weight Loss Surgery Not Recommended?

There are some individuals who should not undergo laparoscopic banding. This includes individuals: - with severe psychiatric illness - who are drug or alcohol addicts - with serious medical disorders which can make surgery risky - with end stage cancer - who are unrealistic in expectations - who are planning a pregnancy in the near future - who think that weight loss may improve their marriage

What are the complications of laparoscopic gastric banding?

Risks of a laparoscopic gastric band procedure include: - The port to inflate the band may leak or not work at all and another surgery may be required - The band may erode and perforate the stomach - The band may slip and be ineffective - Weight loss may not occur as much as one expected

How long does the procedure take?

Laparoscopic gastric banding takes about 1-2 hrs. All patients have to stay in the hospital overnight

How is the band adjusted?

Band Adjustments are done in the x ray department. A fine needle is aced into the pocket created near the abdomen. Water is the injected into this pocket and the band starts to inflate. The procedure is not painful and takes about 10-20 minutes.

When can I return to work?

The majority of individual will be able to return to work in 7-10 days

How much weight will I lose?

At the very best, most individuals will lose anywhere from 20-50% of excess weight. This weight loss is gradual and may not become fully apparent until 2-3 years. Initially most individual lose weight fast and then the weight loss becomes gradual.

Will I have a lot of excess skin after losing weight?

Yes, once you lose weight, excess skin will appear. Once all the desired weight loss has occurred and you are satisfied, a plastic surgeon can easily remove the excess skin. This is normally done at the end of 2-3 years since one is still losing weight.

When can I resume exercise?

The surgery does not affect one¡¯s ability to exercise. Once the incisions are healed, exercise can be resumed in 7-10 days.

Can the band be removed?

Yes, the band can be removed anytime. Because of scars, the abdomen may have to be opened up with a small incision

Once the band is inflated, what will I feel?

Some individuals may feel full but the majority will not have any symptoms. However, a significant number of individuals will complain of nausea, vomiting or a bloated feeling in the initial period when food is eaten. This feeling subsides with time as the individual gets adjusted to the band and the need to eat less.

What happens if I am unable to eat all?

In some cases, the band may be too tight and needs to be deflated. This is the chief advantage of the adjustable band. Once the band is adjusted, the symptoms subside. In some rare cases, the patient is just unable to tolerate the band and thus the band has to be removed.

What happens if I over eat?

Over eating increases the volume of food and can lead to over stretching of the pouch, and thus loss of elasticity i.e. poor emptying. This excess food can also place additional stress on the sutures that are holding the band in place. Occasionally over distension of the stomach can cut the stitches and the band can migrate downwards over the stomach.

What happens if the band slips?

Band slippage is an extremely dangerous and potentially life threatening situation, and always requires urgent surgery. Slippage can cause obstruction, or twisting of the stomach around the band.

What if I get pregnant after the procedure?

There is no problem and it is best to deflate the band so you can eat and nourish your baby. The band can always be tightened after delivery.

Can I take my medications and vitamins?

Sure, the banding procedure does not affect the ability to swallow a pill. Remember swallow the pills with a lot of water.

Can I drink alcohol after the surgery?

Yes, as long as it is in moderation, alcohol is fine and does not affect weight loss.

What can I eat after surgery?

Once the recovery phase of surgery is over, one can eat anything. However, the banding will make you feel full with small amounts of food. It is important to eat a wholesome diet with all the necessary nutrients because one only eats a little food on a daily basis.

How much does the procedure cost?

The cost is variable and includes the fee for the surgeon and the hospital. The average cost ranges from $ 15-30,000.

Is the procedure covered by medical insurance?

Many insurance companies do not cover this procedure but attitudes have been changing since the cost of caring for a thinner patient is much less than that of an obese patient. So phone your insurance company before you embark on this expensive undertaking

Who does this procedure?

The procedure is generally done by general surgeons who have additional training in laparoscopic surgery. Because of the lure of easy money, there is a bandwagon of surgeons who are clamoring for the business of obesity surgery. So ask if your surgeon is board certified, has additional training in laparoscopic procedures and talk to people who have had the procedure. Remember, if in doubt, go seek a second opinion.

What is required of me after the surgery?

Gastric bypass surgery doesn't replace the need for following a healthy diet and regular physical activity program. In fact, the success of the surgery depends in part on your commitment to following the guidelines given to you about diet and exercise. As you consider weight-loss surgery, make sure that you make every effort to exercise, change your eating habits and adjust any other lifestyle factors that have contributed to your excess weight gain.

Final Advice

IF you are not sure about the procedure, you should not get it done.