Laparoscopic adjustable gastric banding for morbid obesity - Home Study Program

AORN Journal, May, 2003 by Dorothy Roedel Ferraro

Morbid obesity, which correlates with a body mass index (BMI) (weight [kilograms]/height [[meters].sup.2]) of 40 or higher, is a chronic, intractable disease that, if left untreated, results in increased morbidity and mortality and a decreased life span. (1) More than 97 million people in the United States are either overweight or obese, (2) resulting in health care costs that approach $70 billion per year. (3) According to the Surgeon General's recent "call to action," the number of people who are overweight or obese have reached nationwide epidemic proportions. In 1999, an estimated 61% of adults in the United States were overweight, as were 13% of children and adolescents. (4) Traditional nonsurgical weight loss methods that attempt to decrease weight through dietary and behavioral interventions often result in disappointing outcomes with a high rate of relapse. (5) Surgery to treat morbid obesity has been recognized by the National Institutes of Health (NIH) as an approach for well-informed and motivated patients for whom the surgical risks are acceptable. (6)

Until recently, surgical options were limited to procedures performed through an open incision (Table 1). These procedures permanently alter the anatomy of the digestive tract (Figure 1) by stapling or bypassing the stomach and a portion of the small intestine or a combination of these procedures. This can result in long-term morbidities, including macronutrient and micronutrient deficiencies and, in rare instances, death. (7) The two surgical weight loss procedures most commonly performed in the United States for morbid obesity have been the Roux-en-Y gastric bypass and vertical banded gastroplasty. (8)

[FIGURE 1 OMITTED]

The Roux-en-Y gastric bypass is both restrictive (ie, limits the amount of solid food the patient is able to ingest) and malabsorptive (ie, decreases intestinal absorption) (Figure 2). During this procedure, staples are used to construct a small, restrictive upper gastric pouch, which then is anastomosed directly to the small bowel, bypassing most of the stomach and some of the small intestine. (9) Vertical banded gastroplasty is a restrictive procedure in which staples are used to make a small stomach pouch; however, no rerouting of the digestive tract occurs (Figure 3). (10)

[FIGURE 2-3 OMITTED]

In June 2001, the US Food and Drug Administration (FDA) approved an adjustable gastric banding system for use in the surgical treatment of morbid obesity (Figure 4). This approval was received after clinical trials were conducted through-out the country between 1996 and 2001. Results of these studies, as well as those of other studies conducted throughout the world, have demonstrated the safety and efficacy of adjustable gastric banding. (11) The gastric band, which is adjustable and reversible if medically indicated, is placed laparoscopically and does not alter the normal anatomy. Since 1993, more than 80,000 adjustable gastric banding procedures have been performed worldwide. (12)

[FIGURE 4 OMITTED]

HISTORY OF GASTRIC BANDING

The concept of stomach banding to treat obesity originated in 1976, when Lawrence Wilkinson, MD, used a strip of synthetic polypropylene mesh as the band, resulting in a reduction of the gastric reservoir. (13) Since that time, variations on this procedure using synthetic polyethylene terephthalate and polytetrafluoroethylene vascular grafts have been performed. (14)

The first adjustable silicone gastric band was introduced in the 1980s by Lubomyr Kuzmak, MD, who added an inflatable portion to the band attached via a tube to an access port that was implanted subcutaneously. (15) This configuration allowed for postoperative adjustments of the size of the opening (ie, stoma) between the upper and lower stomach reservoirs by the addition or removal of saline via a needle inserted into the access port. With the advancement of laparoscopic surgical techniques and a growing demand for an adjustable gastric band that could be inserted without the need for open surgery came the introduction of laparoscopic adjustable gastric banding. Today, the laparoscopic adjustable gastric banding system includes a slip-through buckle with self-locking closure system and a calibration tube to facilitate sizing of the pouch at the time of placement.

RISKS AND BENEFITS

Morbid obesity is associated with serious medical problems, such as type 2 diabetes, hypertension, heart disease, gastroesophageal reflux disease, sleep disorders, and asthma (Table 2). (16) Studies show that even a moderate weight loss after laparoscopic adjustable gastric banding surgery can result in improvements in all of these conditions. (17) Numerous studies show that weight loss following laparoscopic adjustable gastric banding surgery significantly improves patients' quality of life physically, socially, and psychologically. (18) The risks of this surgery are outweighed by the benefits it provides.

Risks. Surgeons report fewer perioperative complications following laparoscopic gastric banding surgery than with other forms of surgery for obesity. (19) The most commonly reported postoperative complication associated with laparoscopic gastric banding is stomach pouch enlargement, which usually is associated with slippage of the stomach wall through the band. (20) The incidence of this complication, however, has been dramatically reduced with surgical technique modifications. One researcher reported a reduction in stomach slippage from 30% in his first 50 patients to 2.5% in a later group of 200 patients. (21) There also have been repons of erosion of the band through the stomach tissue; a large European study showed an erosion rate of 1%. (22) Complications related to the access port and tubing also have been reported, including movement or tilting of the access port, leaking or broken tubing, or infection at the access port site. Better placement and fixation techniques have resulted in fewer of these complications. (23) Rarely, stomach perforation may occur during surgery. (24)