Laparoscopic gastric banding

The application of an adjustable gastric band that reduces the amount of food consumed – gastric banding – helps to reduce body weight and is one of the restrictive methods used in the surgical treatment of obesity.

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Indications for the procedure

First of all, indications for gastric banding concern patients with stage III obesity, that is, with a body mass index (BMI) greater than 40 (kg/m2) and a history of inability to lose weight using traditional weight loss programs (diet and exercise) or medications.

Also, bariatric surgery in the form of gastric banding may be recommended for patients with a BMI> 35, for whom obesity causes serious health problems. The list of these problems includes: type II diabetes (non-insulin-dependent), high blood pressure, cardiovascular diseases, obstructive sleep apnea, decreased lung capacity with asthmatic symptoms, osteoarthritis, and the presence of metabolic syndrome.

Where is gastric banding performed?

It should be borne in mind that all bariatric surgeries without exception – including laparoscopic gastric banding – should be performed in specialized clinics that have:

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

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Preparation

Preparation for gastric banding surgery involves examining patients to determine the presence of other diseases and pathologies that may either be contraindications to this surgery or potentially cause complications.

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

X-rays and ultrasounds of the stomach and all abdominal organs are performed; gastroendoscopy and electrocardiography may be required.

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

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Technique gastric banding

What is an adjustable gastric band? It is a silicone ring with a fastener that is placed around the stomach (fixed to the serous membrane with several sutures). The band covers the body of the stomach in its proximal part - a few centimeters below the cardia (the gastric valve on the border with the esophagus). On the inside of the ring there is a cuff connected by a tube to 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 saline, resulting in compression of the stomach around the circumference, forming a gastric pouch (mini-stomach) with a capacity of no more than 30 ml. Between it and the main cavity of the stomach, an opening is left like a stoma, and the degree of its narrowing is regulated by adding or removing fluid from the cuff. Thus, the entire stomach is involved in the digestion process, as the chyme gradually moves down through the stoma.

When food fills the mini-stomach formed by the bandage, it expands with stretching of the walls, which is perceived by their mechanoreceptors, sending a "satiety signal" to the hypothalamus. Today, this is the generally accepted explanation for the action of the bandage, however, nothing is said about how all other gastric receptors react to restrictive manipulations, because the stomach has a very complex system of biochemically mediated innervation.

Laparoscopic gastric banding is performed under general anesthesia, with the abdominal cavity filled with carbon dioxide (to create an operating space). Four to five punctures (ports) are made on the abdominal wall, through which special endoscopic manipulators are inserted. More highly qualified surgeons can perform this operation through one port (SPL). A small circular "tunnel" is created behind the stomach, where the band is inserted and secured 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 gastrointestinal tract (esophagitis, hernia of the esophageal opening of the diaphragm, gastritis, ulcers of the stomach and duodenum, gastroduodenitis, Crohn's disease, etc.);
• cholecystitis and cholelithiasis;
• pancreatitis;
• severe hypertension, coronary heart disease, chronic lung diseases;
• mental disorders;
• alcohol or drug addiction;
• age under 18 and over 55 years;
• pregnancy and lactation period.

Gastric banding is generally contraindicated unless the potential patient understands the procedure and is not aware of its impact on established eating habits.

Concerns about possible risks (which may outweigh the expected positive results) are the reason for refusing to perform this procedure on patients with a BMI above 50. In such cases, doctors recommend first losing weight to a BMI of 40-45 - undergoing a weight loss program with a controlled diet and exercise.

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Consequences after the procedure

In addition to complications immediately following surgery, more distant consequences are possible after the gastric banding procedure, in particular:

• heartburn (due to reflux of the contents of the gastric bag into the esophagus when the band is positioned too high);
• vomiting and pain in the stomach after eating (if the opening between the mini-stomach and the rest of the stomach cavity is too narrow or if inappropriate food is consumed, causing regurgitation);
• problems with bowel function in the form of constipation or diarrhea, associated mainly with impaired intestinal peristalsis (with a decrease in the amount of food consumed, a decrease in the content of dietary fiber in the diet and insufficient fluid intake);
• Dysphagia (difficulty swallowing) can occur if food is swallowed too quickly or not chewed enough, or when food is dry or very hard;
• deficiency of vitamins (especially B-12, A, D and K) and minerals (calcium, iron, zinc, copper).

According to experts from the American Association of Clinical Endocrinologists (AACE), food complications after gastric banding are caused by the band's internal diameter being too small. As studies have shown, disturbances in the regulation of the pressure cuff filling lead to the fact that two-thirds of patients after gastric banding experience the inability to eat certain foods. And almost a third suffer from persistent vomiting - the main cause of nutritional deficiencies, which can have devastating consequences for bone health, the functioning of the immune, nervous and muscular systems.

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Complications after the procedure

As with any surgical procedure, complications are possible after the gastric banding procedure, which, according to experts from the American Society for Bariatric Surgery, do not exceed 3-5% of cases, and the risk of mortality is 0.1-0.3%.

Most common postoperative complications include injury to the esophagus or spleen, bleeding, secondary infections, pneumonia. In addition, complications characteristic of gastric banding include:

• slippage of the band and dilation of the gastric pouch with the need for re-application of the band;
• irritation, swelling or erosion of the gastric mucosa due to pressure from the band and its migration through the walls due to too much fluid in the cuff;
• fluid leakage from the tube or cuff, requiring replacement;
• the appearance of a hematoma or the development of an infection in the area of the external port;
• External port offset.

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Care after the procedure

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

Post-bandage care consists of ensuring the healing of the punctures (they are treated with antiseptics and covered with a sterile plaster) and following an appropriate gentle diet - very small portions and only homogenized food.

In addition, the patient receives detailed instructions on dietary rules and lifestyle changes that he must strictly follow for a long period of time (usually for life).

Filling the band cuff with liquid is not performed immediately after the operation, but only after the ring has been properly secured to the serous membrane of the stomach. To ensure the optimal size of the opening between the gastric bag and the rest of the stomach and to ensure weight loss, repeated adjustments of the internal diameter of the band are required during the first 12-18 months after installation. During this period, the patient's condition and weight loss will be monitored, so patients should visit the doctor monthly. After body weight has stabilized, the check is performed once a year.

Nutrition after gastric banding

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

Patients undergoing gastric banding need:

• eat five times a day in small portions;
• eat slowly and chew food well;
• do not drink during meals (the volume of the mini-stomach does not allow this);
• drink up to two liters of liquid per day (but not sweet carbonated drinks);
• Do not lie down to rest after eating (to avoid reflux).

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

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Which is more effective: gastric banding or balloon?

The question of the effectiveness of bariatric surgery is one of the main ones for patients suffering from morbid obesity. When deciding on a procedure to limit the volume of the stomach, you should have an idea of the advantages and disadvantages of different restrictive methods. For example, what is more effective: gastric banding or a balloon?

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

Laparoscopic gastric banding, performed under general anesthesia, is a minimally invasive method. 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 light sedation, is inserted through the throat and esophagus using an endoscope, and inflated in the stomach.

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

In addition, the intragastric balloon is placed for a shorter period of time (from 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 stable habit of controlling and limiting the amount of food consumed. From this point of view, for patients with a BMI of 30-35, the balloon is considered more effective than the band. But with a BMI of 35-40 and serious health problems, the band is more suitable.

Reviews and results after gastric banding surgery

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

Other average results after gastric banding surgery are also given: after three months – 20% (of excess weight); after six months – 35%; after a year – 40%, after two years – 50%, and in four years you can get rid of 65% of the extra pounds. (and not all your body weight!). However, almost every fourth patient failed to lose half of their excess weight within five years.

Feedback from 46% of patients in foreign clinics after gastric banding is positive. Almost 19% of patients were dissatisfied. In addition, half of those who were dissatisfied had to have the band removed due to discomfort after the operation.