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Gastric Restrictive Surgery

(Laparoscopic Adjustable Gastric Banding, Vertical Sleeve Gastrectomy, Vertical Banded Gastroplasty)

What is gastric stapling (restrictive) surgery?

Gastric restrictive surgery is a type of bariatric surgery (weight loss surgery) procedure performed to limit the amount of food a person can eat. Bariatric surgery is the only option today that effectively treats morbid obesity in people for whom more conservative measures, such as diet, exercise, and medication have failed.

Illustration of a restrictive surgical procedure for weight loss
Click Image to Enlarge

In these gastric restrictive procedures, the digestive process remains intact and none of the GI tract is bypassed. These operations are of two types. One is designed to separate the stomach into two parts, one of which is a very small pouch that can hold only about one ounce. The second type removes about 80% of the stomach, such that the remaining stomach is much smaller. Because the size of the stomach is reduced so dramatically, these procedures are referred to as restrictive procedures.

After laparoscopic adjustable gastric banding or vertical sleeve gastrectomy, a person can eat only about three-quarters to one cup of food. The food must be well-chewed. Eating more than the stomach pouch can hold may result in nausea and vomiting. Restrictive procedures pose fewer risks than gastric bypass procedures, but they are also less successful because continuous overeating can stretch the pouch so that it accommodates more food.

The types of gastric restrictive  procedures include:

  • Laparoscopic adjustable gastric banding (LAGB). This procedure involves attaching an inflatable band around the top portion of the stomach and tightening it like a belt to separate the stomach into a small pouch that serves as a new, much smaller stomach and the rest of the stomach below the band. The band creates a narrow channel (or stoma) between these two parts of the stomach. This slows the movement of the food from the upper small pouch to the lower stomach. After the procedure, the diameter of the band around the stomach can be adjusted by a doctor by adding or removing saline (salt water). No staples are used in this procedure.
    Like other restrictive procedures, LAGB may not achieve significant weight loss. The U.S. Food and Drug Administration (FDA) approved an LAGB system in 2001 that can be put in place with a laparoscope (a small, thin tube with a video camera attached) rather than with an open incision for patients who are morbidly obese, as indicated by a Body Mass Index (BMI) of 40 or more.

  • Vertical banded gastroplasty (VBG). This procedure uses a combination of staples and a band to create the pouch. There is a dime-sized opening at the bottom of the "new" stomach that opens into the rest of the larger stomach. Plastic tissue or mesh is wrapped around the opening to help prevent the opening from stretching. Weight loss has proven not to be long lasting and this operation is generally no longer performed. Also, the operation causes many unpleasant symptoms after eating that are not well tolerated.

  • Vertical sleeve gastrectomy (VSG). This newer procedure uses staples to remove about 80% of the stomach. The remaining stomach, which is shaped like a "sleeve" will hold approximately one-quarter cup of liquid. Over time, the stomach can expand to hold one cup of food.
    This procedure was initially created as a first step of a two-step surgery (second step surgery involves changing the direction of food in the small intestine for a malabsorption, also called biliopancreatic diversion. Many patients lose the desired amount of weight and do not need this second surgery. Weight loss can be 33 to 60 percent of excess body weight at one year after surgery. Since the rest of the stomach has been removed, this procedure is not reversible.

VBG and LAGB may be performed with a laparoscope rather than through an open incision in most patients. This procedure uses several small incisions for the laparoscopic instruments to visualize the inside of the abdomen during the operation. The doctor performs the surgery while looking at a TV monitor. Laparoscopic gastric surgery usually reduces the length of the hospital stay and the amount of scarring, and often results in quicker recovery than an "open" or standard procedure.

Persons with a BMI of 60 or more or persons who have already had some type of abdominal surgery may not be considered as a candidate for the laparoscopic technique.

The digestive system

The digestive tract
The Digestive Tract. Click to Enlarge

Digestion is the process by which food and liquid are broken down into smaller parts so that the body can use them to build and nourish cells. Digestion begins in the mouth, where food and liquids are taken in, and is completed in the small intestine. The digestive tract is a series of hollow organs joined in a long, twisting tube from the mouth to the anus.

The stomach is where three mechanical tasks of storing, mixing, and emptying occur. Normally, this is what happens:

  • First, the stomach stores the swallowed food and liquid, which requires the muscle of the upper part of the stomach to relax. This increases the volume of the stomach to accept large volumes of swallowed material.

  • Second, the lower part of the stomach mixes up the food, liquid, and digestive juices produced by the stomach by muscle action.

  • Third, the stomach empties the contents into the small intestine.

The food is then digested and dissolved in the small intestine by the juices from the pancreas, liver, and intestine, and the contents of the intestine are mixed and pushed forward (downstream) to allow further digestion.

Reasons for the procedure

Bariatric surgery is performed because it is currently the best treatment option for producing lasting weight loss in severely obese patients for whom nonsurgical methods of weight loss have failed.

Potential candidates for bariatric surgery include:

  • Persons with a Body Mass Index (BMI) greater than 40

  • Men who are 100 pounds over their ideal body weight or women who are 80 pounds over their ideal body weight

  • Persons with a BMI of 35 or more who have another serious weight-related condition such as type 2 diabetes, sleep apnea, heart disease, high blood pressure, or incapacitating osteoarthritis

Because the surgery can have serious side effects, the long-term health benefits must be considered and found greater than the risk. Despite the fact that some surgical techniques can be done laparoscopically with reduced risk, all bariatric surgery is considered major surgery.

Although not all risks with each procedure are fully known, bariatric surgery does help many people to reduce or eliminate some health-related obesity problems. It may help to:

  • Lower blood sugar

  • Lower blood pressure

  • Reduce or eliminate sleep apnea

  • Decrease the workload of the heart

  • Lower cholesterol levels

  • Minimize further worsening of osteoarthritis of lower back, hips, and knees

Surgery for weight loss is not a universal remedy, but these procedures can be highly effective in people who are motivated after surgery to follow their doctor's guidelines for nutrition and exercise and to take nutritional supplements.

There may be other reasons for your doctor to recommend a gastric banding procedure.

Risks of the procedure

As with any surgical procedure, complications may occur. Some possible complications include, but are not limited to, the following:

  • Infection

  • Blood clots

  • Pneumonia

  • Bleeding ulcer

  • Development of gallstones

  • Obstruction or nausea can occur when food is not well-chewed

  • Poor nutrition

  • Scarring inside the abdomen (adhesions)

  • Vomiting due to eating more than the stomach pouch can hold, not chewing food well enough, or eating food too fast

Risks specific to LAGB include erosion of the band into the stomach and "slipping" of the band. This can cause obstruction to the flow of food through the band. For VSG, specific risks include breakdown of the line of staples or bleeding from the staple line. Rarely, stomach juices may leak into the abdomen and emergency surgery may be needed. The most common long-term complication that may develop with LAGB and VSG is that the stomach pouch enlarges.

Risk is reduced with a laparoscopic banding procedure because there is no incision made into the stomach wall.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Before the procedure

  • Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

  • You will be asked to sign a consent form that shows that you understand the operation and its risks. It also gives your doctor permission to perform the procedure. Read the form carefully and ask questions if something is not clear.

  • In addition to a complete medical history, your doctor will perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests. You also should meet with a dietitian and often a psychologist.

  • You will be asked to fast for eight hours before the procedure, generally after midnight.

  • If you are pregnant or suspect that you are pregnant, you should notify your doctor.

  • Notify your doctor if you are sensitive to or are allergic to any medications, latex, iodine, tape, or anesthetic agents (local and general).

  • Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.

  • Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications such as warfarin, aspirin, ibuprofen, naprosyn, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.

  • You may be asked to begin exercising and alter your diet several weeks before surgery.

  • If you are a woman of childbearing age, you may receive birth control counseling so that you do not become pregnant in your first year after surgery due to the risk to the fetus from rapid weight loss.

  • You may receive a sedative prior to the procedure to help you relax.

  • Based on your medical condition, your doctor may request other specific preparation.

During the procedure

Restrictive gastric surgery requires a stay in the hospital. Procedures may vary depending on the type of procedure performed and your doctor's practices.

These operations require you to be fully asleep under general anesthesia. Your doctor will discuss this with you in advance.

Generally, the following process occurs:

  1. You will be asked to remove clothing and will be given a gown to wear.

  2. An intravenous (IV) line may be started in your arm or hand.

  3. You will be positioned lying on your back on the operating table.

  4. If there is excessive hair at the surgical site, it may be clipped off.

  5. A urinary catheter may be inserted.

  6. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.

  7. The skin over the surgical site will be cleansed with an antiseptic solution.

  8. For a laparoscopic procedure, a series of small incisions (usually 1/2 to 1 inch long) will be made. For an open procedure, the doctor will make a single larger incision in the abdominal area. Carbon dioxide gas will be introduced into the abdomen to inflate the abdominal cavity so that the stomach and intestines can easily be visualized.

  9. For a laparoscopic adjustable gastric band procedure, a band with a small reservoir or balloon on the inside will be placed around the top end of the stomach encircling it to create the small pouch that will serve as the new stomach. A narrow passage through the band will connect to the rest of the stomach. The band will be inflated with a salt solution.

  10. For a vertical sleeve gastrectomy procedure, about 80% of the stomach will be removed, and a small sleeve of the stomach will be created with a line of staples.

  11. A drain may be placed in the incision site to remove fluid.

  12. The incision(s) will be closed with stitches or surgical staples.

  13. A sterile bandage or dressing will be applied.

After the procedure

After the procedure, you will be taken to the recovery room for observation. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room.

You may receive pain medication as needed, either by a nurse or by administering it yourself through a device connected to your intravenous line.

You will be encouraged to move around as tolerated while you are in bed, and then to get out of bed and walk around as your strength improves. The first time you get up, ask the nurse to help you, so you do not fall or faint. It is important for you to move around soon after your surgery to prevent the formation of blood clots.

At first you will receive fluids through an IV. That evening or the next day, you will be given liquids such as broth or clear juice to drink. As you are able to tolerate liquids, you may be given thicker liquids, such as pudding, milk, or cream soup, followed by foods that you do not have to chew, such as hot cereal or pureed foods. Some surgeons keep their patients on a liquid diet for 1 to 2 weeks. Your physician will instruct you about how long to stay on liquid until it is time to progress to eat pureed foods after surgery. By 4 to 6 weeks after your procedure, you may be eating solid foods.

You will be instructed about taking nutritional supplements to replace the nutrients lost due to the reconstruction of the digestive tract. You will also be encouraged to maximize protein intake, often with protein drinks.

Before you are discharged from the hospital, arrangements will be made for a follow-up visit with your doctor.

At home

Once you are home, it will be important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up visit in a week or so.

The incision and abdominal muscles may ache, especially with deep breathing, coughing, and exertion. Take a pain reliever for soreness as recommended by your doctor. Aspirin or certain other pain medications called nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the chance of bleeding. Be sure to take only recommended medications.

You should continue the breathing exercises used in the hospital.

You should gradually increase your physical activity as tolerated. It may take several weeks to return to your previous levels of stamina.

You may be instructed to avoid lifting heavy items for several weeks to months, depending on whether the operation was done laparoscopically or with an open technique, in order to prevent strain on your abdominal muscles and surgical incision.

Weight loss surgery can be emotionally difficult because you will be adjusting to new dietary habits and a body in the process of change. You may feel especially tired during the first 4 to 6 weeks following surgery. Exercise and attending a support group may be helpful at this time.

Notify your doctor to report any of the following:

  • Fever and/or chills

  • Redness, swelling, or bleeding or other drainage from the incision site

  • Increased pain around the incision site

Following gastric bypass surgery, your doctor may give you additional or alternate instructions, depending on your particular situation.