Laparoscopic adjustable gastric banding for morbid obesity - Home Study Program

AORN Journal,  May, 2003  by Dorothy Roedel Ferraro

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Fat distribution. Laparoscopic gastric banding in some patients can be technically challenging to the surgical team. Technical difficulty increases when there is a preponderance of abdominal fat (ie, android pattern), a BMI of more than 60, or a combination of both issues. Factors influencing level of difficulty include

* air leaks,

* difficulty with retraction and exposure of the surgical site,

* insufficient trocar and instrument length, and

* limited freedom of movement. (30)

Fat distribution should be assessed preoperatively by calculating a patient's waist-to-hip ratio to determine if laparoscopic adjustable gastric banding surgery is practical. Patients with a massive abdominal girth or who are super morbidly obese can be placed on a medically supervised, very low-calorie liquid diet for one to four weeks preoperatively. This is believed to result in a modest decrease in the size of the liver, thus improving the ability to retract the liver during surgery and adequately expose the esophagogastric junction and cardia of the stomach. Another benefit of a very low-calorie liquid diet preoperatively is the prevention of last supper syndrome. This is a phenomenon that has been observed in bariatric patients in which caloric intake markedly increases in the weeks or months preceding surgery in response to their anticipated postoperative food deprivation. One study demonstrated an average weight gain of almost 10 lbs in a group of patients awaiting bariatric surgery. (31) The benefits of preoperative nutrition therapy with a very low calorie liquid diet include

* decreased weight,

* improvement in nutritional status,

* improved maneuverability, and

* decreased surgical risks. (32)

The resulting modest decrease in body weight preoperatively from the liquid diet improves glycemic control, blood pressure, and pulmonary status, thus optimizing comorbidities before surgery.

Food preferences. There is no definitive evidence indicating which preoperative dietary behaviors are predictive of favorable outcomes following laparoscopic adjustable gastric banding. One group of researchers identified the following dietary features that distinguish people who are obese:

* dietary disinhibition (ie, eating anything and everything you want with no regard for caloric or nutritional values);

* frequent consumption of light meals and snacks;

* high fat intake;

* low consumption of alcohol, fruits, and vegetables; and

* night eating. (33)

Due to the purely restrictive nature of this procedure, patients whose preoperative tendency was to eat large portions of nutrient-dense foods three or fewer times daily (ie, volume-eaters) tend to have better weight loss than those patients who eat small amounts of food throughout the day (ie, grazers).

In a group of 375 patients undergoing either vertical banded gastroplasty or laparoscopic adjustable gastric banding, one group of researchers reported better weight loss and maintenance in patients who consumed a relatively large amount of sweet foods. (34) Another group of researchers, however, reported that preoperative and current sweet-eating behaviors do not influence weight loss outcomes after laparoscopic adjustable gastric banding. They concluded that sweet-eating behavior should not, therefore, be used as a preoperative selection criterion for bariatric surgery. (35)