Editing Gastric band


== Technique for placement ==

* Supine, generally with     surgeon on right and assistant on left
*
* Place gastric band in     peritoneum
* Divide gastrohepatic     ligament/pars flaccida , checking for anterior branch of vagus nerve and     aberrant left hepatic artery
* Expose right crus of     diaphragm
* Blunt dissect under     oesophagus to reach the left crus and stomach at Angle of His
* Pull the narrow end of the     band through this tunnel, from left to right
* Thread the band through     locking mechanism, and adjust buckle so that it lies on the lesser curve.     Ensure you can pass a 5mm grasper between the band and the stomach.     Plicate the anterior stomach wall over the band with interrupted sutures.
* Pull the silastic tubing     through the paramedian port, and connect it to the access port, which is     secured to anterior rectus sheath. Avoid kinking of tube.

== Post-op: ==

* Overnight stay
* Initially place an empty     reservoir, and add saline in 1-1.5mL aliquots to produce a desired weight     loss of 1-2kg/week

== Technique for removal: ==

* Ports: Palmer's point, then     alongside port, then 5mm RUQ and 5mm LUQ, and 5mm subxiphoid for     Nathanson's
* Follow channel down to band     by diathermying fibrotic tissue on top of it
* Divide channel near band
* Use scissors to cut the band     at the buckle, and pull the band out
* Cut down onto port, and     release fascial sutures, and pull it all out
* Check it all came out
* Close skin

== '''Early complications''' (<30 days) ==

* Infection/sepsis
* Food bolus obstruction
* Haemorrhage
* Slippage
* Reflux
* Nausea +/- vomiting

== '''Late complications''' ==

* Prolapse/slipped band
** Presentation
*** Sudden-onset vomiting
*** Gurgling sensation reported       by patient
*** Dysphagia
*** Epigastric pain
** Complications
*** Pouch necrosis
** Key investigations
*** AXR erect

* The band should sit between 8     and 2 o'clock - if AXR demonstrates a 'flatter' angle, i.e. between 10 and     4 o'clock, it's probably slipped
* Equated to a phi angle of     >58 degrees (angle between the vertical axis and the horizontal plane     of band)
* O sign - front on band -     indicates posterior slippage
* 1-2cm of gastric mucosa above     band (virtual pouch)

* Can start management based on     this, no need for swallow in most cases

* Radiological findings
** Abnormal lie
** Air-fluid level above band
** Stasis above band
** Delayed transit through the      band
* Management
** Deflate band - in an      emergency setting any needle can be used
** Contrast swallow/CT with PO      contrast
** Needs explantation or      revision, but this can often be done via discussion with the original      surgeon in the outpatient/delayed acute setting - especially if contrast      is getting through
** Remove acutely if      unremitting pain, concerning features on CT (no contrast, so complete      obstruction) or peritonism

* Erosion
** Loss of restriction (weight      gain), port infection (if recurrent port infections, need to organise      gastroscopy), acute infection
** Can be vague symptoms of      sepsis/infection, not necessarily abdominal pain
** 1% per year
** Investigations
*** Gastroscopy - can generally       be removed endoscopically, provided buckle is visible from the inside.       Can use endoscopic band cutter. If it all comes out, don't need to do       any laparoscopy usually as the small hole for the tubing will generally       not turn into a fistula.
*** Another option would a lap       distal gastrotomy and remove with instruments inside stomach.
* Reflux
* Erosive oesophagitis
* Abnormal oesophageal function
** Dilation is common
** 70% have abnormal      oesophageal peristalsis, including simultaneous or failed peristalsis
** Removal of the band      generally improves pseudo-achalasia or mega-oesophagus
* Pouch enlargement
* Gastric prolapse
* Vomiting
* Tubing-related problems
* Leakage of reservoir
* Weight loss failure/lower     average weight loss
** In one large study, 71% had      re-operation by 7 years
** Not as good long-term      outcomes as LSG or RYGB
* Nutritional deficiencies are     uncommon

[[Category:Bariatrics]]