Laparoscopic Adjustable Gastric Banding
Laparoscopic adjustable gastric banding
(LAGB) is the safest and least invasive operation that produces
long-term weight loss. Keyhole surgery, through 4 small
incisions, is used to place an adjustable band around the
top of the stomach. The operation takes about an hour, with
a hospital stay of 24 hours and a return to normal activities
in a week or two. Weight loss can be as good or better than
the other operations, but patients need to work hard with
the band to achieve the best results. Unlike the other
surgical options, LAGB is fully reversible, although this
is not advised as weight regain will occur.
How does Laparoscopic
Adjustable Gastric Banding work?
 When the band is well adjusted it has a physical and psychological
effect. Physically it restricts food intake. When the patient
eats a small meal, it sticks in the stomach pouch above
the band, making the patient feel full. Like an old-fashioned
egg timer the food slowly empties from the pouch into the
stomach, the rate of emptying can be slowed down by tightening
the band and eating the right sort of foods. By reducing
portion sizes the band causes slow, steady weight loss.
The band also has a psychological effect, when well adjusted
patients report control of their appetite and a diminished
interest in food. These effects will only occur if the
band is in a good position, it takes time and good training
for surgeons to learn how to position a band well in all
patients. Some patients are easy and some are very difficult.
Similarly the band needs to be kept at the right tightness
which is why good follow up should be included with any
surgical package.
The Surgery
The patient is admitted to hospital
on the day of surgery. A general anaesthetic is needed for
the surgery, it cannot be performed under local or spinal
anaesthesia. Four small cuts are made in the upper abdomen,
three are 0.5 cm long and one is about 2 long. Using a digital
telescope and long operating instruments the surgeon places
a lockable adjustable band around the upper stomach, with
a 20 ml pouch of stomach above the band. The volume of the
pouch is important and is measured using an inflatable balloon,
passed through the mouth into the stomach. If the pouch
is too small or the band is to high on the stomach it can
be difficult to achieve good satiety and there is a risk
of long-term damage to the oesophagus. The stomach is then
stitched over the band to the pouch, so that the LAGB
is firmly held in a tunnel of stomach. Securing the band
in this way is important and reduces the risk of the band
slipping in the future. The band is connected to an inflation
port or “button” that is stitched to the muscle,
just below the ribs on the patient’s left hand side.
It is completely hidden under the skin. Dissolvable sutures
are used to close the incisions
After Surgery
After surgery, the patient spends about an hour in the recovery
area of theatre, being closely observed before returning
to the ward. The patient has an intravenous drip in their
arm for fluid, which will usually be removed later that
night, oxygen through a face mask, heart monitoring through
leads on their chest, and blood pressure monitoring with
a cuff on their arm. There may also be compression stockings
around the calf, which help the blood circulation through
the legs preventing thromboses.
When the patient returns to the ward they will be allowed
to drink and then start a sloppy diet. The pain after surgery
isn’t usually too bad and can usually be controlled
with paracetamol, ibuprofen and sometimes a small dose of
morphine. Patient are usually discharged from hospital the
day after surgery.
After discharge, it is important to rest and eat carefully.
Most people need a week or two off normal activities before
returning to work. The pain shouldn’t be too severe
and should be reasonably controlled with paracetamol and
an anti-inflammatory pain killler such as ibuprofen. Patients
shouldn’t drive for at least a week and should notify
their insurer before driving again. A soft diet is recommended
for the first few weeks after surgery, as the swelling from
surgery disappears most patients find they can eat without
much restriction. This is normal and doesn’t mean the
LAGB won’t work. Most medication can be taken as normal,
it is sometimes necessary to break tablets.
Follow up after surgery
Good follow up is essential after LAGB surgery to get a good
result, which is why we include after care with our packages.
The band won’t work unless it is kept optimally tight
and the patient complies with a suitable diet avoiding
liquid calories such as chocolate. Regular appointments
with a dietician will help a patient learn to work with
their band. The band should be thought of as a tool that
has been fitted to the patient to help them control their
food intake. A band alone, without good patient input,
won’t give good weight loss.
The band is usually adjusted in clinic. Sometimes a radiolgical
adjustment will be recommended if the port is difficult to
access or the position of the LAGB needs to be checked. Achieving
good restriction may take two or three appointments a month
or so apart. Once restriction is achieved, less frequent
adjustments will be needed to maintain optimal restriction.
Even a year or two after surgery patients will need occasional
adjustments.
Band adjustments are normally performed by a specially trained
nurse or a doctor. It usually only takes a couple of minutes
and doesn’t need any form of anaesthetic or particular
preparation. A specially designed needle, a Huber needle,
is passed through the skin into the LAGB port. Usually the
patient then sits up and while drinking water the band is
tightened by injecting saline. After a fill the patient should
be able to drink, although slower than normal. After a fill
it is sensible to wait in clinic for a short time and drink
a couple of glasses of water before going home. After a fill,
the patient should return to a semi-solid diet until they
are used to the additional restriction. It is best not to
plan a fill before a holiday or a flight abroad.
Expected
weight loss with Laparoscopic Adjustable Gastric Banding
Although research would suggest that average weight loss
with the LAGB is less than with a Roux-en Y gastric bypass,
in our experience with good selection LAGB patients can
do just as well if not better than with the bypass. The
key to a good outcome is choosing the right operation for
each patient. Patients who work well with the band can
lose 70 or 80% of their excess weight and some will achieve
a normal weight and BMI. In research the average weight
loss after LAGB is skewed by the patients who have been
poorly selected for LAGB and lose very little weight.
Risks of Laparoscopic
Adjustable Gastric Banding surgery
DEATH
LAGB surgery is usually safe, Streamline Surgical has a zero
mortality for LAGB surgery. Nevertheless it is not without
risk, worldwide the risk of death with LAGB is 1 in a thousand.
INTRA-ABDOMINAL INJURY & CONVERSION
TO AN OPEN OPERATION
Again the risk of internal injury is low, it is possible
to injure the stomach, spleen or liver. If this were to happen
it may be necessary to convert from keyhole surgery to an
open operation through an incision from the bottom of the
breast bone to the umbilicus (tummy button). This would mean
a longer hospital stay and a slower recovery. The risk of
internal injury can be reduced by shrinking the liver with
the pre-operative milk diet.
BLEEDING
Bleeding after LAGB is rare, but were it to occur a blood
transfusion may be necessary or a re-operation to stop the
bleeding if it was uncontrollable. None of Streamline’s
LAGB patients have needed a blood transfusion or re-operation
for bleeding. Bruising under the around the wounds can occur
after surgery
INFECTION
Infection after LAGB is uncommon, occasionally wounds can
become inflamed after surgery and may need to be treated
with antibiotics. Were the port or the band to become infected
after surgery it would need to be removed. Occasionally,
the port can become infected after a band fill. If this were
to occur the port may need to be removed temporarily and
replaced when the infection has resolved.
BAND SLIPPAGE
The LAGB can slip on the stomach, this is usually called
a gastric slip and can occur in up to 1 in fifty patients.
If it occurs acutely it needs urgent treatment to prevent
serious harm. In an acute gastric slip the stomach slips
up through the band, causing blockage of the stomach. In
an acute slip the patient will suffer severe upper abdominal
pain associated with uncontrollable vomiting. Left untreated
the blood supply to the stomach above the band becomes impaired
which can result in strangulation and peritonitis secondary
to a hole in the stomach. Strangulation of the stomach in
an acute gastric slip can be prevented by emptying the band.
Any Accident and Emergency Department should be able to do
this. If emptying the band does not relieve the gastric
obstruction the band may need to be re-positioned or even
removed. Sometimes a gastric slip will occur with persistent
vomiting, but little abdominal pain. This is of less concern
than an acute gastric slip and doesn’t need such urgent
treatment. It will usually be diagnosed using a barium x-ray.
As with an acute slip the band may need emptying or re-positioning.
Stitching the stomach carefully, at the time of the initial
surgery, is the best way to prevent a gastric slip.
BAND OR GASTRIC EROSION
Occasionally the LAGB can erode through the wall of the stomach,
this is rare and reported in up to 1 in 300 cases. A gastric
erosion may result from an unrecognised injury to the stomach
at the time of surgery or from the band being too tight.
It is not always easy to diagnose, some patients will have
very few symptoms while others will loose their restriction,
suffer from recurrent infections in their port and feel unwell
due to generalised infection. It is usually diagnosed by
looking into the stomach with an endoscope through the mouth.
The LAGB will need to removed either using an endoscope or
with further keyhole surgery.
OESOPHAGEAL DILATATION
Occasionally the oesophagus can become dilated, causing food
to stick in it. This usually occurs if the band is placed
too high on the stomach at the junction between the oesophagus
and the stomach or if the band is too tight. It is usually
diagnosed with a barium x-ray. The band may need to be loosened
or if badly positioned it may need to be re-sited with further
keyhole surgery
ANAESTHETIC COMPLICATIONS
Chest infections and heart attacks are rare after laparoscopic
adjustable gastric banding as most patients are otherwise
fit and well. Occasionally patients will develop a deep vein
thrombosis, a clot in the veins of the leg. Left untreated
these can move to the lung, a pulmonary embolism, causing
serious breathing difficulties. These are best avoided. Lots
of steps are taken in theatre and after surgery to minimise
the risk. Patients can help to decrease their risk by giving
up smoking before surgery, maintaining a good fluid intake
after surgery and walking after surgery.
Information for women of child bearing age
FERTILITY AND CONTRACEPTION
Obesity can cause infertility. Many overweight women find
they are infertile, don’t have periods and don’t
use contraception. With weight loss many patients start to
ovulate again, have periods and with this increased fertility,
unplanned pregnancies can occur. It is important to use contraception
after LAGB surgery. Barrier methods, coils and hormone injections
are the most reliable methods. Although absorption of drugs
is not affected by the surgery, vomiting can reduce the effectiveness
of the oral contraceptive pill.
PREGNANCY WITH A LAGB
Pregnancy within the first year of LAGB surgery is not recommended.
But after a year it is safe to become pregnant. Many healthy
babies have been born to Mothers who have had LAGB surgery
with us. The band does need to be managed during pregnancy.
It isn’t always necessary to empty the band, as this
will result in severe weight gain. Mild to moderate restriction
is safe for the baby will control the mother’s weight
and can reduce the complications of pregnancy related to
obesity such as diabetes and eclampsia.
Recommended diet after Laparoscopic Adjustable
Gastric Banding
Streamline’s dietician will see you
before surgery to advise you on the appropriate diet. A low
fat healthy diet is recommended although there may be some
foods that can’t be tolerated after surgery. Particularly
red meat and bread can be difficult to eat when the band
is tight and may become stuck in the pouch causing vomiting.
When choosing food with a band it sometimes helps to think
of the band as being like a funnel. Rather than choosing
foods that would pass easily through a funnel, foods that
would stick and take time to pass through a funnel should
be chosen as these will give a prolonged feeling of fullness.
Weight loss can be sabotaged by choosing foods that would
pass easily through a funnel such as chocholate, crisps,
sweets, ice cream, alcohol, smoothies and milky coffees as
all the calories from these liquid foods will be absorbed.
Will a Laparoscopic Adjustable Gastric
Banding work for me?
At your initial consultation, the surgeon
seeing you will make a full assessment of your mobility,
pre-existing illnesses, diet, dieting history, eating behaviour
and with you work out whether you will achieve your weight
loss goal with laparoscopic adjustable gastric banding.
Although there are no absolute rules, patients who do well
with LAGB will usually be of a younger age, normal mobility
and body mass index below 50kg/m2 . They often have a history
of good weight loss with dieting, but are unable to sustain
their weight loss. They will usually have a savoury tooth,
favouring large portions and are rarely full. They tend to
have disciplined eating habits without excessive snacking
between meals or grazing behaviour. Conversely patients who
have poor weight loss with the LAGB tend to be older, less
active and have a higher body mass index. People who find
it difficult to diet or have very slow weight loss with moderate
calorie restriction may not lose weight well with the band.
Patients who cannot avoid sweets, crisps, chocholate,
alcohol and ice cream usually do badly with the band. Similarly
patients who have uncontrolled erratic eating behaviour,
including bingeing, may not have the discipline needed to
work well with laparoscopic adjustable gastric banding.
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