Laparoscopic Gastric Banding

Operations that are designed to cause significant and long-lasting weight loss in patients who are severely obese, such as laparoscopic gastric banding, are forms of bariatric surgery, a term derived from the Greek words baros ("weight") and iatrikos ("pertaining to a physician"). Bariatric surgery helps patients achieve weight loss through two mechanisms: restriction and malabsorption.[1] Laparoscopic gastric banding, described in this article, falls under the subcategory of restrictive bariatric surgery.

Other forms of bariatric surgery are gastric bypass (see Laparoscopic Gastric Bypass) and sleeve gastrectomy. Currently, laparoscopic gastric banding is not performed as frequently as it once was[1] ; nevertheless, many patients still have bands in place, and the procedure may still be useful for selected patients.[2, 3]

Obesity is caused by a combination of genetics, environmental issues, and behavioral factors.[4, 5]  Consumption of high-calorie foods, consumption of too much food, and a sedentary lifestyle all work together to create this condition. Obesity is associated with the development of diabetes mellitus, hypertension, dyslipidemia, arthritis, sleep apnea, cholelithiasis, cardiovascular disease, and cancer.

More than 100 million Americans (65% of the adult population) are overweight.[4]  Obesity is the second-leading cause of preventable death in the United States, after smoking. Obesity-related diseases account for 400,000 premature deaths each year.[4]

Obesity can be treated medically and surgically. Medical treatment for obesity is challenging, because the amount of weight lost is relatively insignificant and patients tend to regain most of the lost weight. A 2010 prospective, randomized controlled trial in 50 adolescents demonstrated that a greater percentage of patients achieved a loss of 50% of excess weight with laparoscopic gastric banding than with lifestyle intervention.[6]

Body mass index (BMI) describes relative weight for height and correlates significantly with an individual’s total body fat.[5]  BMI is based on height and weight and applies to adults of both sexes. It is calculated in either of two ways, as follows[4, 7] :

• BMI = weight (kg)/(height [m]) ²
• BMI = weight (lb)/(height [in.]) ² × 703

In 1991, the National Institutes of Health (NIH) provided a consensus statement for selecting bariatric surgery candidates.[7] Patients were considered candidates for surgery if they met one of the following criteria:

• BMI greater than 40
• BMI of 30-40 plus one of the following obesity-associated comorbidities: severe diabetes mellitus, pickwickian syndrome, obesity-related cardiomyopathy, severe sleep apnea, or osteoarthritis interfering with lifestyle

To be candidates for bariatric surgery, patients should have attempted, without success, to lose an appropriate amount of weight through lifestyle changes or through supervised dietary changes.[7] Patients must also comply with postoperative diet and exercise.

A prospective single-center study by Juodeikis et al that followed 103 patients (39 superobese, 64 nonsuperobese) for 5 years found that laparoscopic adjustable gastric banding (LAGB) was less effective in the superobese patients, with poorer weight loss results and lower overall BAROS (Bariatric Analysis and Reporting Outcome System) scores.[8]  

In 2008, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) issued guidelines for the clinical application of laparoscopic bariatric surgery.[9] The SAGES guidelines noted that well-selected patients who have a BMI higher than 60 or are older than 60 years may benefit from laparoscopic bariatric surgery by experienced surgeons and that adolescents may also benefit from such surgery.

In February 2011, the US Food and Drug Administration (FDA) expanded the use of the Lap-Band System (Apollo Endosurgery, Austin, TX) for patients with a BMI of 30-34 and having any obesity-associated comorbidities.

Contraindications for laparoscopic gastric banding include the following:

• History of substance abuse
• An active major psychiatric disorder
• End-stage organ disease (eg, cardiac, hepatic, or pulmonary)
• Stomach or intestinal disorder or infection
• Inability or unwillingness to follow dietary recommendations

Several studies found that the long-term outcomes of laparoscopic gastric banding appeared not to be as good as those of gastric bypass.[10, 11]  In the long term, there is a substantial risk that band removal may prove necessary. A study by Tammaro et al found the risk of removal to be higher in women, younger patients, and individuals with a BMI higher than 50.[12]

Furbetta et al reported long-term results after LAGB in 3566 patients over a period of more than 20 years to investigate outcomes in terms of efficacy, complications, and reoperations.[13] Of the 3566, 926 (71.6%) completed at least 10 years of follow-up, and 180 (58.4%) reached 15 years. Mean excess weight loss was 49% at 10 years, 52.6% at 15 years, and 59.2% at 20 years. The main late complications were pouch herniation-dilation (5.8%) and erosion (2.5%); the total reoperation rate was 24.1%. Results were best in young patients with a high BMI but were also satisfactory in elderly patients and those with a low BMI.

Li et al performed a meta-analysis of 33 studies (N = 4109) with the aim of comparing LAGB and laparoscopic sleeve gastrectomy for the treatment of morbid obesity and related diseases.[14] They found laparoscopic sleeve gastrectomy to be a more effective procedure than LAGB for morbidly obese patients, yielding a higher percentage of excess weight loss and greater improvement or remission of type 2 diabetes mellitus (though no significant improvement with regard to hypertension).

In a study that included 276 patients in whom revision was required after LAGB because of weight regain or insufficient weight loss, Dayan et al compared the 5-year outcomes of one-anastomosis gastric bypass (OAGB) and sleeve gastrectomy.[15]  Major early complication rates were comparable. OAGB patients had a lower BMI than sleeve gastrectomy patients (31.9 vs 34.5 kg/m2), greater total weight loss (25.1% vs 18.8%), and a higher resolution rate for type 2 diabetes (93.3% vs 66.6%); Resolution rates for hypertension did not differ significantly.

Laparoscopic gastric banding requires an instrument tray that includes the following:

• Grasper
• Dissector
• Laparoscopic banding device
• Sutures
• Different length and sizes of trocars
• Nathanson liver retractor

Anesthesia

General anesthesia is required for this procedure.

Positioning

The patient is positioned comfortably in a semilithotomy position. The surgeon stands between the patient’s legs or on the patient’s right side, and the first assistant stands on the left side of the patient and holds the camera. The surgeon should be standing comfortably with arms and elbows in an abducted position. Before starting the procedure, the surgeon should adjust the monitors to eye level.

Preparation for surgery

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient have been formulated by the American Society for Metabolic and Bariatric Surgery.[16]  A preoperative low-calorie diet seems to help decrease the size of the liver. Care should be taken to ensure that the patient is kept well hydrated.

Operative details

The abdomen is entered under direct visualization by placing a 5-mm port with a 30º lens. A 15-mm trocar and a 5-mm trocar are placed as working points. A 5-mm first assistant port and a Nathanson retractor to elevate the left lateral section of the liver are placed (see the video below). The trocars should be positioned at least a fist-length apart; this allows the surgeon to use both hands comfortably.

The dissection begins with a gentle blunt release of gastrophrenic attachments at the angle of His. The gastrohepatic window is entered, and dissection at the right crus is performed to create a retrogastric tunnel.

A band of appropriate size is introduced through the 15-mm trocar. Before insertion, the balloon of the device should be checked to avoid placement of a defective band. When the band is in place, the tubing is grasped by the grasper, retracted through the retrogastric tunnel, and locked into position anteriorly. Three gastrogastric sutures are placed to create a gastrogastric plication around the band and hold it in position. An additional gastrogastric suture is placed below the band.

The tubing is exteriorized and connected to a port, which is secured to the abdominal wall fascia.

The Nathanson retractor and the trocars are removed under direct visualization, and incisions are closed in standard fashion.

Complications of laparoscopic gastric banding include the following:

• Infection
• Bleeding
• Pouch enlargement
• Band slippage ^[17]
• Band erosion ^[18]
• Dilated esophagus
• Vomiting
• Heartburn
• Perforation of stomach
• Injury to spleen
• Mechanical device failure
• Mortality of 0.08%

A systematic review and meta-analysis by Majdoubeh et al suggested that symptomatic hiatal hernia could be a direct complication of gastric banding; further research would be required to confirm a causal relation and define the mechanism.[19]

In a retrospective review of 156 patients who underwent laparoscopic adjustable gastric banding over a 4-year period, Papadimitriou et al reported an overall complication rate of 15.4% and a major complication rate of 3.2%.[20]  The authors noted that the procedure carried certain complications even when performed by a surgeon experienced in laparoscopic surgery. Subset analysis suggested that the learning curve for laparoscopic gastric banding is at least 50 procedures.