Laparoscopic gastric banding

The imposition of an adjustable gastric band that reduces the amount of food consumed - gastric banding - helps to reduce body weight and refers to restrictive (restrictive) methods that are used in the surgical treatment of obesity.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Indications for the procedure

First of all, indications for gastric banding concern patients with obesity of the third degree, that is, with a body mass index (BMI) exceeding 40 (kg / sq. M.), And a history of inability to reduce weight using weight loss programs based on traditional methods diet and exercise) or medication.

Also,  bariatric surgery  in the form of a gastric banding can be recommended for patients with a BMI> 35, in which obesity causes serious health problems. In the list of these problems: diabetes mellitus type II (insulin-independent), high blood pressure, diseases of the cardiovascular system, obstructive sleep apnea, a decrease in lung volume with asthmatic symptoms, osteoarthritis, and the presence of  metabolic syndrome.

Where do stomach bandages?

It should be borne in mind that all bariatric operations without exception - including laparoscopic gastric banding - should be carried out in specialized clinics that have:

• experience in bariatric surgery (at least 25-30 operations per year);
• relevant conditions and equipment (including resuscitation unit);
• qualified practicing surgeons who are proficient in the technique of this operation and have repeatedly performed it;
• specially trained medical personnel (qualified nurses, nutritionists, anesthesiologists, rehabilitation specialists, cardiologists, endocrinologists, etc.).

[10], [11], [12]

Preparation

Preparing for a gastric banding operation involves examining patients with finding out the presence of other diseases and pathologies that may be either contraindications to the operation, or are potentially capable of causing its complications.

Do clinical and detailed biochemical blood tests, urine analysis. Depending on the anamnesis and complaints of a particular patient, the level of acidity of the stomach is determined.

X-ray and ultrasound of the stomach and all abdominal organs are carried out; you may need gastroendoscopy and electrocardiography.

On the day of bandaging, the patient should have an empty stomach, so it is allowed two or three hours before the procedure to drink some tea.

[13], [14]

Technique of the gastric banding

What is an adjustable gastric band? This is a silicone ring with a clasp-fastener that is placed around the stomach (with a few seams fixing on the serous membrane). The bandage covers the body of the stomach in its proximal part - several centimeters below the cardia (the gastric valve at the border with the esophagus). On the inner side of the ring there is a cuff connected by a tube with an external opening - an access port under the skin on the outside of the abdomen or on the sternum.

Through this tube, the cuff is filled with sterile physiological solution, as a result of which the stomach is clamped around the circumference to form a gastric bag (mini-stomach) with a capacity of no more than 30 ml. Between it and the main cavity of the stomach leave a hole like a stoma, and the degree of its narrowing is regulated by adding or removing liquid from the cuff. Thus, during the digestion involved the whole stomach, as the chyme gradually moves down through the stoma.

When food fills the mini-stomach formed by the constriction, it expands with the stretching of the walls, which is perceived by their mechanoreceptors sending a "satiety signal" to the hypothalamus. To date, this is a common explanation for the bandage, however, it does not say anything about how all other gastric receptors react to restrictive manipulation, because the stomach has a very complex system of biochemically mediated innervation.

Laparoscopic gastric banding is performed under general anesthesia, with the filling of the abdominal cavity with carbon dioxide (to create an operative space). On the abdominal wall, four or five punctures (ports) are made, through which special endoscopic manipulator tools are inserted inside. Surgeons of higher qualifications can perform this operation through a single port (SPL). Behind the stomach creates a small circular "tunnel", where a bandage is wound and fixed around the stomach. All manipulations are controlled by visualizing them on the monitor.

Contraindications to the procedure

The main contraindications for gastric banding include:

• inflammatory diseases of the digestive tract (esophagitis, hernia of the esophageal opening of the diaphragm, gastritis, gastric ulcer and duodenal ulcer, gastroduodenitis, Crohn's disease, etc.);
• cholecystitis and cholelithiasis;
• pancreatitis;
• severe hypertension, ischemic heart disease, chronic lung disease;
• mental disorders;
• alcohol or drug addiction;
• age under 18 and over 55;
• pregnancy and lactation.

Gastric banding is usually contraindicated if a potential patient does not understand the essence of the procedure and does not realize its effect on established eating habits.

Fears about possible risks (which may outweigh the expected positive results) are the reason for refusing to perform this procedure for patients with a BMI above 50. In such cases, doctors recommend first to lose weight before BMI 40-45 - to undergo a weight loss program with a controlled diet and physically loaded.

[15]

Consequences after the procedure

In addition to complications immediately after surgery, more long-term consequences after gastric banding procedure are possible, in particular:

• heartburn (due to reflux of the contents of the gastric bag into the esophagus at too high a position of the bandage);
• vomiting and pain in the stomach after eating (if the opening between the mini-stomach and the rest of the cavity of its cavity is too narrow or the unsuitable food is used, causing the regulation);
• problems with the work of the intestines in the form of constipation or diarrhea, associated mainly with the violation of intestinal peristalsis (with a decrease in the amount of food consumed, a decrease in the content of dietary fiber in the diet and insufficient use of liquid);
• Dysphagia (difficulty swallowing) can occur if the food is absorbed too quickly or not enough to chew, and when the food is dry or very hard;
• lack of vitamins (especially, B-12, A, D and K) and minerals (calcium, iron, zinc, copper).

According to the experts of the American Association of Clinical Endocrinology (AACE), food complications after the gastric banding procedure are caused by too small internal diameter of the bandage. As studies have shown, violations in the regulation of filling the pressure cuff lead to the fact that two-thirds of patients after gastric banding experience the inability to eat certain foods. And almost one third suffers persistent vomiting - the main cause of nutritional deficiency, which can have devastating consequences for bone health, functioning of the immune, nervous and muscular system.

[16], [17], [18]

Complications after the procedure

As with any surgical intervention, there may be complications after the gastric banding procedure, which, according to the experts of the American Society for Bariatric Surgery, does not exceed 3-5% of cases, and the risk of mortality is 0.1-0.3%.

Most often, postoperative complications include injury to the esophagus or spleen, bleeding, secondary infections, pneumonia. In addition, there are such complications characteristic for gastric banding, such as:

• slippage of the bandage and dilatation of the gastric bag with the need to re-bandage;
• irritation, edema or erosion of the gastric mucosa due to the pressure of the bandage and its migration through the walls due to too much fluid in the cuff;
• leakage of liquid from the tube or cuff, requiring replacement;
• the appearance of a hematoma or the development of infection in the zone of the external port;
• displacement of the external port.

[19], [20], [21]

Care after the procedure

Usually the patient is in a medical facility for three days, but in many foreign clinics this procedure is carried out on an outpatient basis, and in the evening of the same day the patient goes home.

Care after the bandage procedure is to ensure the healing of punctures (spend their antiseptic treatment and close with a sterile patch) and observe the appropriate gentle diet - very small portions and only homogenized food.

In addition, the patient receives a detailed instruction on the rules of nutrition and lifestyle changes, which he has to perform rigorously for a long time (most often for life).

Filling the cuff of the bandage with liquid is not performed immediately after the operation, but only after the ring is properly fixed on the serous membrane of the stomach. For an optimal size of the opening between the gastric bag and the rest of the stomach and ensuring weight reduction, the inner diameter of the bandage needs to be adjusted repeatedly in the first 12-18 months after installation. During this period, the patient's condition and weight loss will be controlled, so patients should visit the doctor on a monthly basis. After stabilizing the body weight, the test is performed once a year.

Nutrition after gastric banding

In principle, nutrition after gastric banding is not a diet, because it should consist of normal healthy food, which should be chewed thoroughly - to achieve consistency of the paste before swallowing. This texture will minimize possible digestive problems in the stomach bag (mini-stomach). So nutritionists do not recommend switching to soups, mashed potatoes, casseroles and fruit cocktails, which easily and quickly pass below the bandage, thus increasing the calorie content of food.

Patients with gastric banding are necessary:

• eat five times a day in small portions;
• eat slowly and eat well the food;
• during meals do not drink (the volume of the mini-stomach does not allow this);
• consume up to two liters of liquid per day (only non-sweet carbonated drinks);
• do not go to bed after a meal (to avoid reflux).

It is very important to change your habits not only in eating, but to increase the level of physical activity in any accessible way. For example, you can walk every day.

[22], [23], [24], [25], [26]

What is more effective: gastric banding or balloon?

The question of the effectiveness of bariatric surgery is one of the main issues for patients suffering from morbid obesity. Deciding on the procedure for limiting the volume of the stomach, you should know what advantages and disadvantages have different restrictive methods. For example, what is more effective: gastric banding or balloon?

The advantages of both methods are that they are reversible: the gastric band can be removed and the intragastric balloon blown out and extracted.

Laparoscopic gastric banding, performed under general anesthesia, refers to minimally invasive methods. And the installation of a balloon in the stomach cavity is a non-invasive and, in fact, non-surgical procedure, since a soft silicone balloon, after mild sedation, is injected through the pharynx and esophagus with an endoscope, and inflated already in the stomach.

Both procedures can help to reduce weight by one third of the original, but, as experts emphasize, the effectiveness of the bandage can decrease if the bandage moves from the place of its installation (and this occurs in about 10% of patients). And in such cases complications can arise. The introduction of a balloon, as a rule, does not give complications.

In addition, the intragastric balloon is placed for a shorter time (6 to 12 months), and its purpose is not only to create a feeling of satiety with less food, but also to gradually modify the eating behavior itself, contributing to the development of a persistent habit of controlling and limiting the amount of food absorbed. From this point of view, for patients with a BMI of 30-35, a balloon is considered more effective than a bandage. But with BMI 35-40 and serious health problems, it is the bandage that is more suitable.

Reviews and results after the operation of gastric banding

According to one data, after laparoscopic gastric banding, patients with an initial BMI of 40-50 per year lose an average of 30% of their excess weight, and a year after the procedure - 35%.

There are other average statistical results after the gastric banding operation: in three months - 20% (overweight); after half a year - 35%; in a year - 40%, in two years - 50%, and for four years you can get rid of 65% of extra pounds. (and not of all body weight!). Nevertheless, almost every fourth patient for five years failed to lose half of his excess weight.

Reviews 46% of patients from foreign clinics after gastric banding are positive. Almost 19% of patients were dissatisfied. In addition, half of those who were unhappy because of discomfort after the operation had to remove the bandage.