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Extreme obesity is a worldwide epidemic. It is the second most common cause of preventable death in the United States, second only to smoking. Bariatric surgery, the surgical management of obesity, has demonstrated a substantial reduction in overall mortality in extremely obese individuals, according to multiple long-term studies. Bariatric surgery was first conducted in the 1960s as the jejunoileal bypass procedure. This procedure showed good weight loss results but involved numerous complications, particularly issues about malabsorption. This activity describes the technique, indications, and complications of laparoscopic band surgery and highlights the role of the interprofessional team in the management of obese patients. Objectives: Describe the indications for laparoscopic band placement. Explain the technique for placing a laparoscopic band. Summarize the complications of laparoscopic band placement. Explain interprofessional team strategies for optimizing care coordination and communication to advance the appropriate and safe use of laparoscopic band surgery and improve clinical outcomes. Access free multiple choice questions on this topic.

Extreme obesity is a widely recognized worldwide epidemic. The rates of obesity have exponentially risen in the United States during the last 2 decades. Accordingly, the prevalence of 30.5% has escalated to 41.9%. Similarly, the mortality rates of this disorder increased. It is the second most common cause of preventable death in the United States after smoking.[1] Bariatric surgery, the surgical management of obesity, has demonstrated a substantial reduction in overall mortality in extremely obese individuals, according to multiple long-term studies.[2] Bariatric surgery was first conducted in the 1960s as the jejunoileal bypass procedure. This procedure showed good weight loss results that involved numerous complications, especially malabsorption.[3] Over time, surgeons worked to develop techniques with limited complications. The Roux-en-Y gastric bypass was introduced in 1977 and became the procedure of choice by the 1980s. The nonadjustable gastric band procedure was introduced in the late 1970s with poor results, but the first adjustable gastric band was placed in 1985. The results of the adjustable band were released in 1986. They demonstrated improved weight loss with decreased complications compared to nonadjustable gastric banding. The first laparoscopically-placed adjustable gastric band (LAGB) was placed in 1993. Due to its technical ease, it became one of the more popular weight loss surgeries in Europe and Australia in the late 1990s. Laparoscopic adjustable gastric banding was approved in the United States in 2001. Its popularity grew annually until 2008, then began to decline rapidly. The decrease in its use is attributable to the introduction of sleeve gastrectomy. The laparoscopic sleeve gastrectomy was introduced in 1999. Its long-term results as a stand-alone procedure became apparent in the late 2000s. In 2008 the indications for laparoscopic sleeve gastrectomy were published. By 2016 it had become the most commonly performed bariatric surgery in the United States. By 2015, laparoscopically adjusted gastric banding constituted only 5.7% of all bariatric procedures performed in the United States. It is rarely done.[3][4][5]

Bariatric surgery was first conducted in the 1960s as the jejunoileal bypass procedure. This procedure showed good weight loss results that involved numerous complications, especially malabsorption.[3] Over time, surgeons worked to develop techniques with limited complications. The Roux-en-Y gastric bypass was introduced in 1977 and became the procedure of choice by the 1980s. The nonadjustable gastric band procedure was introduced in the late 1970s with poor results, but the first adjustable gastric band was placed in 1985. The results of the adjustable band were released in 1986. They demonstrated improved weight loss with decreased complications compared to nonadjustable gastric banding. The first laparoscopically-placed adjustable gastric band (LAGB) was placed in 1993. Due to its technical ease, it became one of the more popular weight loss surgeries in Europe and Australia in the late 1990s. Laparoscopic adjustable gastric banding was approved in the United States in 2001. Its popularity grew annually until 2008, then began to decline rapidly. The decrease in its use is attributable to the introduction of sleeve gastrectomy. The laparoscopic sleeve gastrectomy was introduced in 1999. Its long-term results as a stand-alone procedure became apparent in the late 2000s. In 2008 the indications for laparoscopic sleeve gastrectomy were published. By 2016 it had become the most commonly performed bariatric surgery in the United States. By 2015, laparoscopically adjusted gastric banding constituted only 5.7% of all bariatric procedures performed in the United States. It is rarely done.[3][4][5] The 2 primary mechanisms bariatric surgery allows a patient to lose weight are restriction and malabsorption. Restriction refers to achieving weight loss by limiting the intake of calories. Malabsorption refers to altering the intestinal tract to bypass a certain length of the small intestine. This bypass results in a decrease in the absorption of ingested nutrients. Some procedures change bodily hormonal concentrations, leading to weight loss and resolution of co-morbidities. The laparoscopic adjusted gastric bypass is strictly a restrictive procedure, which may explain why its long-term results are inferior to other bariatric surgeries.[6] It should be noted that bariatric surgeries were originally categorized into three main subgroups a. restrictive, b. malabsorptive, or c. restrictive-malabsorptive procedures. However, it has been demonstrated that all the anatomical alterations in bariatric surgeries would result in either transient or permanent physiological changes.[7] Although the performance of this procedure is rare in the modern era, many patients may continue to have adjustable gastric bands. Therefore, it is necessary to educate clinicians on the laparoscopic adjusted gastric banding technique to diagnose and treat any potential complications safely and promptly.

Laparoscopic adjusted gastric banding has the lowest mortality of all the bariatric procedures, ranging from 0.02% to 0.1%.[12] It carries a 3% 30-day morbidity and a 12% rate of late complications, though this varies among the literature.[13][14] Early Complications Deep vein thrombosis: Pulmonary embolism is the leading cause of death following laparoscopic adjusted gastric band surgery in many series.[15] These patients should receive appropriate venous thromboembolism prophylaxis. Esophageal or gastric perforation: The most common location for this is the retro gastric space. It is usually associated with an undiagnosed hiatal hernia. If a perforation occurs and is close to where the band will be placed, the procedure should be aborted. Esophagogastric obstruction: This can be an immediate postoperative obstruction caused by a tight gastric band. It is not typically seen due to the larger diameter of later band designs. This can be prevented by removing the perigastric fat pads to allow for adequate room for the gastric band.[16] Late Complications

Esophageal or gastric perforation: The most common location for this is the retro gastric space. It is usually associated with an undiagnosed hiatal hernia. If a perforation occurs and is close to where the band will be placed, the procedure should be aborted. Esophagogastric obstruction: This can be an immediate postoperative obstruction caused by a tight gastric band. It is not typically seen due to the larger diameter of later band designs. This can be prevented by removing the perigastric fat pads to allow for adequate room for the gastric band.[16] Late Complications Gastric prolapse, or a “slipped band,” is characterized by the lower stomach herniating superiorly through the device. It can be classified as an anterior or posterior slippage of the fundus past the band; the anterior is more common. The patient will experience sudden-onset food intolerance or reflux symptoms. Diagnosis begins with a plain abdominal radiograph. Normally the band is oriented diagonally from 2 to 8 o’clock and points towards the left shoulder. A slipped band will appear oriented more horizontally from a 10 to 4 o’clock position and will point towards the left hip. Confirmation is generally done with an esophagram. Treatment should be initial deflation of the band to temporarily alleviate the patient’s symptoms. Definitive management includes a reoperation and one of the following techniques: laparoscopic band repositioning, removal with or without replacement of the band, and conversion to another bariatric procedure such as sleeve gastrectomy or Roux-en-Y gastric bypass.[17] Rarely, gastric ischemia and necrosis may ensue. Gastric prolapse had a much higher prevalence in the 1990s, secondary to the laparoscopic adjusted gastric band procedure done with the perigastric technique. This procedure involved a retro-gastric tunnel that entered the lesser sac, resulting in much more freedom and movement of the stomach. This freedom of movement allowed for posterior fundal herniation through the band. With the advent of the pars flaccida technique, the rate of prolapse has decreased from 15% to 4%.[18]

Gastric prolapse, or a “slipped band,” is characterized by the lower stomach herniating superiorly through the device. It can be classified as an anterior or posterior slippage of the fundus past the band; the anterior is more common. The patient will experience sudden-onset food intolerance or reflux symptoms. Diagnosis begins with a plain abdominal radiograph. Normally the band is oriented diagonally from 2 to 8 o’clock and points towards the left shoulder. A slipped band will appear oriented more horizontally from a 10 to 4 o’clock position and will point towards the left hip. Confirmation is generally done with an esophagram. Treatment should be initial deflation of the band to temporarily alleviate the patient’s symptoms. Definitive management includes a reoperation and one of the following techniques: laparoscopic band repositioning, removal with or without replacement of the band, and conversion to another bariatric procedure such as sleeve gastrectomy or Roux-en-Y gastric bypass.[17] Rarely, gastric ischemia and necrosis may ensue. Gastric prolapse had a much higher prevalence in the 1990s, secondary to the laparoscopic adjusted gastric band procedure done with the perigastric technique. This procedure involved a retro-gastric tunnel that entered the lesser sac, resulting in much more freedom and movement of the stomach. This freedom of movement allowed for posterior fundal herniation through the band. With the advent of the pars flaccida technique, the rate of prolapse has decreased from 15% to 4%.[18] Band erosion: The incidence of band erosion into the stomach wall increases with time but remains between 1% and 2% in the literature.[19] These are typically manifested by delayed port site infections, abdominal pain, or failure to suppress the appetite despite band adjustment. The diagnosis is confirmed with endoscopy. Treatment involves an operation, removal of the band, repair of the gastric wall, and drainage. Delayed replacement of the gastric band should be done in 3 months. Device malfunctions: These can be characterized by various complications, including device leaks leading to failure of band adjustment, tube kinking, port dislodgment, and port site infection. Leaks can occur via tubing disconnection, port puncture, or band puncture. The port may become dislodged from the fascia and flip, rendering the port inaccessible.

Device malfunctions: These can be characterized by various complications, including device leaks leading to failure of band adjustment, tube kinking, port dislodgment, and port site infection. Leaks can occur via tubing disconnection, port puncture, or band puncture. The port may become dislodged from the fascia and flip, rendering the port inaccessible. Band obstruction: This can be secondary to an overinflated band, which is most common, or a low band placement due to technical errors or a missed hiatal hernia. This will lead to a gastric pouch and esophageal dilation with esophagitis that can result in esophageal dysmotility, such as megaesophagus or pseudo-achalasia, in chronic cases.[20] Diagnosis is with an esophagram demonstrating esophageal and gastric pouch dilation. Treatment is the deflation of the band and imaging to monitor for the resolution of the gastroesophageal dilatation. If conservative management fails, an operation to revise or remove the band is required.[21]

For bariatric surgery, the patient must be evaluated by an interprofessional team before being a surgical candidate. This team includes a nutritionist, a psychiatric specialist, the surgical team, the nursing staff, and the primary care clinician. It is recommended but not required to conduct a preoperative esophagogastroduodenoscopy before laparoscopic adjusted gastric band surgery. A clinician must be familiar with bariatric procedures and their complications. Bariatric surgery has proven highly efficacious in the treatment of obesity. The laparoscopic adjusted gastric band procedure is rarely done. However, many patients have previously undergone this surgery and may present with complications unique to this procedure. These pathologies must be understood, recognized, properly evaluated, and treated promptly.