Paul Leeder The gastric band has been available as an aid to weight loss for over 30 years. The first adjustable gastric band was reported to have been placed in 1986. Since this time, it is estimated that over 860 000 of the most popular gastric band have been placed worldwide. The first gastric bands were nonadjustable. A permanent material was placed around the top of the stomach in order to create restriction to the natural passage of food. Later developments included an element of adjustability as it became clear that one size did not fit all patients. The most common material used was solid silicon, and the adjustability was provided via a distensible balloon mechanism, inflated with liquid. Although the silicon was considered impermeable, the liquid used was iso‐osmotic, in an attempt to prevent any significant changes in volume over time. Gastric band surgery gained acceptance in the United States following US Food and Drug Administration (FDA) approval of the ‘LAP‐BAND’ system in 2001, followed by the REALIZE band in 2007. While the use of the gastric band has been popular in Europe, the Middle East and Australia since the 1990s, the US market led to a rapid expansion worldwide. A decade later, the use of the gastric band has reduced, but it still remains the procedure of choice in over 10% of primary bariatric procedures carried out annually. There are broadly two types of gastric band available, produced by four manufacturers. The large volume low pressure band – LAP‐BAND (ReShape Lifesciences, USA) and REALIZE/SAGB band (Ethicon Endosurgery, USA) (discontinued manufacture in 2016) – and the smaller volume higher pressure band ‐ Heliogast (Helioscopie, France) and Midband (MID, France). The first adjustable bands accommodated a very small fill volume (up to 4 ml). These have since been largely superseded by higher volume bands that submit the stomach wall to a lower pressure. The reduced pressure effect of the larger volume bands is thought to result in fewer local gastric complications. Surgical options for the treatment of obesity ebb and flow as part of the general surgical ‘Zeitgeist’. Treatment options are partly driven by public demand, manufacturer company marketing and individual surgical experience with different techniques. Very little of these changes is governed by good quality scientific data. The prospectively collected database of UK public health bariatric procedures has marked a steady decline in gastric band insertion over the last five years. Despite requests, companies will not offer data of current gastric band sales, as being commercially sensitive. Registry data, however, suggests that tens of thousands of bands continue to be placed worldwide. The biggest seller is the ubiquitous ‘LAP‐BAND’ (ReShape Lifesciences, USA). It is estimated that currently 80% of bands placed worldwide are of the LAP‐BAND. The LAP‐BAND (Figure 15.1) is currently produced in two sizes, the AP Standard (Small) system (APS) and the AP Large system (APL). The size placed depends on the surgeon’s assessment of the size of the stomach and surrounding fat at the time of surgery. The fill volume of each varies, up to 10 ml of fluid for the APS and 14 ml for the APL. Although the initial diameter is wider for the large AP, the final diameter is the same for both the types of bands. On average, patients experience satiety after fewer adjustments with a smaller volume gastric band. There is some evidence that weight loss is greater with the smaller diameter bands. Figure 15.1 The LAP‐BAND adjustable gastric band system. Source: Courtesy of ReShape Lifesciences, USA. The classic misconception is that of the pouch above the gastric band acting like a new ‘small stomach’. While the band is placed several centimetres below the gastro‐oesophageal junction, the stomach above acts as a virtual pouch, not as a store or repository for food. The effect of food passing through the band is to stimulate afferent vagal nerve fibres of the proximal stomach. Sensitive stretch nerve fibres produce a feeling of early, prolonged satiety. People with appropriate adjustments do not feel hungry with a band. Radiological contrast studies show that an adequately chewed food bolus will traverse the band after about six peristaltic waves. This usually takes an average of one to two minutes. As long as eating is slow, all food will pass into the distal stomach by the time the meal is completed. Ideally, a food bolus should be allowed to pass through, before each subsequent bite. The process of pouch stretching and vagal nerve stimulation works optimally with textured foods. A small portion of textured food, chewed carefully over a period of no longer than 20 minutes, should provide prolonged satiety for most of the day. The combination of reduced portion size, slowed eating and early satiety can result in gradual but sustained weight loss. Gastric band surgery is currently indicated by the International Federation of Surgical Obesity (IFSO) and has FDA approval as an aid to weight loss in patients with a body mass index (BMI) of 40 or 30 with co‐morbid conditions that can be improved with weight loss. The gastric band should not be recommended to patients who are not able to commit to the lifelong dietary and lifestyle changes that would be required for any weight‐loss programme. Patients should have tried non‐surgical methods before any surgical intervention can be recommended. Surgery should not be offered to anyone who is pregnant or have conditions or behaviours that would make them poor surgical candidates. The development of the gastric band in the 1990s coincided with the worldwide explosion of laparoscopic (key‐hole) surgery. Minimal access surgery and a safe reproducible technique have led to gastric band surgery becoming one of the safest forms of weight‐loss surgery. Laparoscopic surgery still requires a full general anaesthetic, with complete muscle relaxation. The gastric band is placed through a narrow retro gastric tunnel, made approximately 2 cm below the gastro‐oesophageal junction. The fat pad that contains branches of the vagus nerve is usually included within the band. Once the band is locked together (each band device has a different method of completing this), the band is secured anteriorly by the placement of sutures. Non‐absorbable ‘gastro gastric’ sutures are generally used to fix the band in position, over the gastric cardia. If a hiatus hernia is identified at the time of surgery, it is important that this is repaired during the same procedure. Hiatal repair can reduce the incidence of both reflux and band slippage after placement. Placement of the gastric band port is most commonly within a subcutaneous pocket, over the left rectus sheath. Other placement options include pre‐sternal position or over the ribs. A position over bone may be easier to identify for adjustment, but may give an unsightly appearance and occasional pain. The author prefers a pre‐muscular position, on the anterior abdominal wall. Attachment to the rectus sheath is generally well tolerated by the patient and allows access by simply tensing or distending the anterior abdominal muscles. Various methods of port placement have been used. Most commonly, sutures or bespoke clip application devices are employed. Despite their use, one of the most common post‐operative complications is rotation or malposition of the gastric band port. Therefore, great care should be taken with port placement. The band tubing should run a smooth, unobstructed course from the top of the stomach, through the abdominal wall muscle, onto the secured port position. Unnecessary lengths of tubing, kinks and twists should all be avoided, in order to prevent future complications. Most surgeons ask their patients to take a very low calorie ‘liver shrinking’ diet pre‐operatively, with the aim of improving access to the top of the stomach. Post‐operatively, it is advisable for patients to mobilise straight away, often as part of an enhanced recovery programme. Many units now perform uncomplicated gastric band surgery as a day case procedure. Post‐operatively, patients are usually placed on a regime of an initial oral liquid diet, followed by a slow build up to more textured food choices. This process can take four to six weeks. During the immediate perioperative phase, patients are expected to lose 5–10 kg of weight. Long‐term medication or nutritional supplementation is not normally required following gastric band surgery, although a general multivitamin is advised during the early weight‐loss phase. Once the patient tolerates a textured diet, it is important to schedule the first band adjustment. As weight is lost, the restriction experienced may reduce, resulting in the need for a further band adjustment. On average, patients require two to five adjustments in the first year, followed by one to two adjustments in the second year. Further adjustments beyond this time are more unusual but may occasionally be required. A sudden lack of satiety or return of hunger may represent a problem with the band, such as a tube leak. Post‐operative band adjustments are generally accepted to follow the pattern of green, yellow and red zones, as proposed by Paul O’Brien (Figure 15.2). An optimally adjusted band results in gradual weight loss and satisfaction with small portions. This is described as the ‘Green Zone’. If the patient’s weight stabilises, their portion size increases and they find themselves looking for food, and they are within the ‘Yellow Zone’. This may require a further band adjustment in order to edge a patient back into the green zone. ‘Red Zone’ symptoms include regular regurgitation of solid foods, night‐time reflux and maladaptive eating. These symptoms denote an over tight band that requires some fluid to be removed from the band system. The author would recommend that fluid is removed as a matter of urgency, in order to prevent the development of pouch dilatation or band slippage. Caution, however, should be taken not to remove too much fluid. Complete band deflation may resolve the symptoms immediately but is likely to result in insatiable hunger and resultant rapid weight regain. This may become a situation that is very difficult to rectify, even with later re‐inflation. Figure 15.2 The optimal gastric band adjustment. Source: Reproduced with kind permission of Dr Paul O’Brien, Monash University, Melbourne, Australia. A carefully planned band adjustment programme should allow the patient to maintain early satiety with small portion sizes, while avoiding symptoms of over tightness. Patients may find that they cannot tolerate dry meat, or very starchy foods, but it is not normal for a patient to experience regular vomiting with an optimally adjusted band. Unexplained regurgitation of food more regularly than once or twice per week, with reflux, is usually a symptom of an over tight band. Care should be taken to prevent the band becoming too tight. This may result in a ‘quick win’ of early weight loss as a result of dysphagia to solid foods. Eventually, an overly tight band can also lead to a poor eating behaviour. Poor or ‘maladaptive’ eating is defined by a patient who makes poor food choices in order to live with an over tight gastric band. Choices are often softer or even liquid food options. These are started to prevent symptoms of regurgitation and obstruction but may be simply to allow for time‐pressured eating. The result of maladaptive eating is that the stomach stretch fibres may not be stimulated in the same way, prolonged satiety may not be achieved and, as a result, a higher calorie intake may be consumed. An over tight gastric band may paradoxically then lead to weight gain. Maladaptive eating behaviours can prove to be extremely difficult to resolve. The recommendation of taking fluid out of a band can often be met with negative reactions, as a patient becomes dependent on an overly tight band. Even the suggestion of deflation may result in the patient not returning for further follow‐up. Previously accepted practice was to deflate a gastric band during a period of illness or pregnancy. Generally, this is not routinely necessary as a healthy, well‐balanced diet can be maintained through an optimally adjusted band. Band deflation should therefore only be advised in the state of severe hyper‐emesis. Equally, most medicines can still be taken in their usual tablet form with a gastric band. Liquid options rarely need to be prescribed. It is generally accepted that anti‐inflammatory medication should be avoided in order to prevent gastric ulceration. In the situation where NSAIDs cannot be stopped, a long‐term proton pump inhibitor should be prescribed concomitantly. In the authors experience, if a patient fails to gain early satiety, hitting the ‘green zone’ soon after surgery, they become disillusioned and can rapidly lose faith in the band. Some patients never quite reach this ‘sweet spot’ of adjustment and do not work well with the band. A small percentage of patients move directly from yellow to red zones, with no in between. Some patients can take several years to work out what the band is doing, before finally learning to work with the band. As long as the band remains in the correct position, it is never too late to return to the gastric band to help with weight loss in the future. If you are seeing a patient for the first time, it is important that you gain a record of the type of band placed in order to avoid over filling. After consultation, an initial adjustment is recommended under fluoroscopic guidance, to view the band position and type. The adequacy of the adjustment can then be checked with a contrast swallow test. The plain X‐ray should show an angle between band and spine of between 4° and 58°. This is known as the ‘phi’ angle. The ideal liquid swallow would identify a concentric, proximal gastric pouch, with the size of a small onion or shallot (Figure 15.3). The contrast should take one to two minutes or six peristaltic waves to leave the oesophagus and pass through the band into the distal stomach. When managed and adjusted appropriately, a gastric band can produce a feeling of sustained satiety and decrease in hunger over the course of the day. Both of these factors can slow down the process of eating and lead to reduced calories intake, with reduced portion size. Weight loss with a gastric band is generally slow and sustained over a 2–3‐year period. There is good evidence that the gastric band is a safe and effective form of weight loss in the medium term. Sustained, meaningful weight loss has been reported up to 20 years beyond band placement (Figure 15.4). There is also evidence of improved quality of life following band placement, which is related to the degree of weight lost. Figure 15.3 Contrast swallow X‐ray showing the optimal position and angle of a gastric band together with an ideally sized proximal gastric band pouch. Resolution or improvement of weight‐related medical conditions can and does occur after gastric band surgery. The health benefits of gastric banding are very much dependent on the degree of weight loss achieved. There is no significant recorded hormonal effect following a gastric band, unlike in other forms of weight loss surgery. As a result, the resolution of co‐morbid conditions may take longer to achieve. There is a common misconception that gastric band surgery should be reserved for patients who are younger, with a lower BMI and fewer co‐morbidities. Interestingly, there is very little evidence to support this assumption. In fact, most well run studies appear to demonstrate that gastric band surgery can be effective in controlling weight and medical conditions such as diabetes, irrespective of age, BMI or severity of disease. There is general consensus that good outcomes following gastric band surgery are reliant on a comprehensive follow‐up programme. Potential patients need commitment and access to long‐term follow‐up. Perhaps a band should not be recommended where there are limited clinical resources and long distances to travel for follow‐up visits. Figure 15.4 Weight loss expressed as % excess weight loss (EWL) ± 95% CI for the 20‐year period of follow‐up after laparoscopic adjustable gastric band. Source: From O’Brien et al. (2019)/Springer Nature/CC BY 4.0. It is important to remember that morbid obesity is a lifelong, incurable disease. It is wrong to think that a single intervention will solve all problems. We do not expect a joint replacement to last a lifetime. Health funding should have similar goals and expectations for weight‐loss surgery. Bariatric surgeons are guilty of overplaying the near ‘miraculous’ results seen with their interventions. The good studies are few and follow‐up is poor. The largest prospective randomised study (By‐Band‐Sleeve, NIHR 09/127/53) to investigate the outcomes of weight‐loss surgery is coming to the end of recruitment at the time of writing. It is the author’s hope that the ‘By‐Band‐Sleeve’ study will enable future clinicians to offer reliable information to patients in order to make informed treatment choices. There is good evidence from randomised controlled trials that gastric band placement can be a successful intervention for weight loss and treatment of co‐morbidities, compared to the best available non‐surgical treatments. Studies similarly demonstrate equally effective weight loss with the gastric band, compared to other common weight‐loss procedures, beyond 10 years. The rate of weight loss and resolution of co‐morbidities can be different, but most studies demonstrate irrefutable, meaningful weight loss with a gastric band beyond five years from placement. While gastric bands may require re‐operation over time, most of these are for minor procedures, such as replacement of the band port. Reported rates of band removal are hugely variable. Most packages of care involve follow‐up for up to two years. Within this time, the rate of band removal is relatively low. In longer term follow‐up studies, over 40% of patients required re‐operation beyond 19 years of follow‐up. Some single centre follow‐up studies have reported a band removal rate of up to 71% after 10 years, although the reasons for removal are not made clear. A more recent prospective longitudinal study identified an explant rate of only 8.74% at five years. This may represent improved techniques of both placement but also follow‐up, and closely matches the author’s own data of 7.81% of bands removed at 10 years. The long‐held assumption was that the pouch acts a new stomach that stores food above the band. The pouch was thought to take 15–20 minutes to empty completely after eating. More recent studies have identified that the stomach above the band acts as a virtual pouch, and when functioning optimally, it should empty within one to two minutes, with no actual physical restriction to meal size. This emptying process should occur between each mouthful and does not affect gastric emptying overall. Despite beliefs to the contrary, pre‐existing reflux should not be a contra‐indication to gastric band surgery. An optimally adjusted gastric band can be good treatment for mild reflux. Symptoms of reflux over the post‐operative period are unusual and suggest either a poorly adjusted band or the development of a complication, such as pouch dilatation or band slippage. New reflux symptoms need to be investigated if they do not resolve immediately following a small band deflation. Although fewer gastric bands are being placed worldwide, these are still many hundreds to thousands of patients that currently have bands in place. The gastric band does carry the risk of complications, and patients can present to primary care or a variety of specialty areas. Some of these complications are related to the general risks of operating on a high‐risk patient with morbid obesity, and some are directly related to the band itself. While complications are rarely life threatening, some reports suggest that the gastric band carries the highest overall rate of complications compared to all bariatric procedures. Published re‐operation rates vary from 8 to 78% over the lifetime of the band. The need for re‐operation may be for relatively minor problems, such as changing or repositioning of the gastric band port. In the event of slippage or pouch dilatation, the band may need to be repositioned, replaced or removed. Some authors would advocate converting to another bariatric procedure at the same sitting. The incidence of band erosion is rare and has been reduced with new techniques and the use of low pressure bands. Most surgeons would advocate band removal as the only reasonable option in the event of erosion. Further weight‐loss surgery after band erosion is not routinely recommended (Table 15.1). The rare, life‐threatening complication is often as a result of delay in treatment or misdiagnosis. Any patient that is unwell with abdominal pain or vomiting in the presence of previous weight‐loss surgery should have their case discussed with a bariatric surgery centre to ensure that an easily treated problem is not missed. Most acute band problems can be successfully managed with a simple band deflation. The adjustable gastric band can be a useful aid to successful weight loss. Although it has been superseded as a preferred method of weight‐loss surgery, it is still one of the safest surgical procedures available. Most good studies demonstrate that the adjustable gastric band can result in sustained, long‐term weight loss, with potential resolution of comorbidities. Further good randomised studies are required in order to define the exact nature of each surgical procedure and their long‐term results, with a good health economic model. The band is without doubt the cheapest and safest option available but may not be as effective as more radical options regarding long‐term weight loss and comorbidity resolution. There is a voiced concern currently, regarding the sustainability of the band, with its reported high need for re‐operation and removal over the longer term. Despite long‐term studies confirming the efficacy of the gastric band, the majority of bariatric surgeons worldwide have abandoned the gastric band in favour of procedures that are less reliant on such intensive follow‐up. Ultimately, the gastric band should still be considered a valid option for weight loss. No surgical intervention works on its own, but requires commitment from the patient and support from their health professional team. While up to 50% of bands may have to be removed, the gastric band has an excellent safety profile and should still be considered within the panoply of treatment options for morbid obesity. Table 15.1 Complications of gastric band.
15
Laparoscopic Adjustable Gastric Banding – Technique and Outcomes
History of the Gastric Band
How the Band Works
Indications
Operative Technique
Follow‐Up
Outcomes
Common Misconceptions
Gastric Bands Do Not Work
Gastric Bands Are Temporary and Have to Be Removed After a Certain Time
Gastric Band Stops Food Going into the Stomach
Gastric Bands Cause Reflux
Complications
Port and tubing problems:
The most common need for re‐operation is for the replacement or reposition of a worn, leaking or misplaced gastric band port.
Gastric band slippage:
A gastric band can move distally so that a larger portion of the stomach locates above the band. Food preferentially stays within the slipped upper stomach, resulting in symptoms of regurgitation and reflux. A band slippage usually requires re‐operation.
Pouch dilatation:
The proximal gastric pouch can stretch over time, resulting in a large amount of stomach above a gastric band. This is usually as a result of a chronically tight gastric band. A large pouch can result in similar problems to those encountered with a band slippage, but if small, can be managed with a gastric band deflation.
Gastric band erosion:
A band can wear itself through the gastric wall and end up inside the stomach. The process of erosion is usually slow and rarely produces severe symptoms apart from dyspepsia and an associated lack of restriction.
Inadequate weight loss:
Success with the gastric band is heavily reliant on a good follow‐up programme. The band will not work satisfactorily unless it is adjusted appropriately. Poor follow‐up is likely to result in a poor outcome. A loose band will not produce adequate restriction to alter eating habits. An overtight band may result in early weight loss but is ultimately likely to fail as the patient develops poor, maladaptive eating behaviours with nutritionally poor, high‐calorie liquid foods.
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