Gastric band
Technique for placement
[edit | edit source]- 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:
[edit | edit source]- 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:
[edit | edit source]- 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)
[edit | edit source]- Infection/sepsis
- Food bolus obstruction
- Haemorrhage
- Slippage
- Reflux
- Nausea +/- vomiting
Late complications
[edit | edit source]- Prolapse/slipped band
- Presentation
- Sudden-onset vomiting
- Gurgling sensation reported by patient
- Dysphagia
- Epigastric pain
- Complications
- Pouch necrosis
- Key investigations
- AXR erect
- Presentation
- 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