Laparoscopic Adjustable Gastric Banding (LAGB)

“Being healthy and fit is not a fad or trend, it is a lifestyle!”

Laparoscopic gastric banding is a reversible, surgical procedure for weight loss in which an adjustable gastric band made of silicon is applied on the outer surface of the stomach. This divides the stomach in a smaller upper pouch and a larger lower pouch. The band is connected to a tube that connects it to a port which is placed below the skin in the abdomen. Laparoscopic adjustable gastric banding works on the principle of food restriction and leads to a weight loss of about 45 to 50%. Laparoscopic gastric banding also leads to a significant improvement in associated co-morbidities like type 2 diabetes, high blood pressure, high cholesterol, gout, obstructive sleep apnoea, joint diseases etc.

Laparoscopic gastric banding was a popular procedure in India till about a decade ago. Over the years owing to less than satisfactory results, lap band surgery has gone out of favour with doctors and patients alike.

Eligibility for laparoscopic gastric banding

The IFSO- APC (International Federation for Surgery for Obesity and Metabolic Disorders – Asia Pacific Chapter) guidelines for weight loss surgery are as under:

Bariatric surgery/obesity surgery/weight loss surgery must be considered for the treatment of obesity for acceptable Asian candidates with BMI ≥ 35 Kg/m² with or without any associated diseases.
Bariatric surgery/metabolic surgery must be considered for the treatment of type 2 diabetes or metabolic syndrome for patients who are inadequately controlled by lifestyle alterations and medical treatment for acceptable Asian candidates with BMI ≥ 30 Kg/m².
Bariatric surgery/metabolic surgery may also be considered as a non-primary alternative to treat inadequately controlled type 2 diabetes or metabolic syndrome for suitable Asian candidates with BMI ≥ 27.5 Kg/m².

Lap band surgery is not recommended routinely to patients nowadays as it did not show good weight loss results in the long term. However, in case of morbidly obese adolescents, it is still a good option. Lap band surgery is a reversible operation and does not alter the gastro-intestinal anatomy. For morbidly obese adolescents who are yet to complete their growth, lap band surgery forms a good weight loss option and is a significant stop gap weight loss measure. Once they achieve the desired growth, the band can be removed and converted to another bariatric procedure which may be deemed the most suitable for the patient at that point of time.

Preparation before the procedure

First step is a consultation with the doctor and the team to decide on the eligibility for gastric banding surgery. A detailed medical history, diet recall and a complete physical and psychological assessment will be performed at this time.
Once we have decided to go with ahead with gastric banding surgery, you will need to undergo a battery of tests. You may also need to see a diabetologist, endocrinologist, nephrologist, chest physician etc based on your clinical profile and associated co-morbidities.
You will also need to be on a high protein liquid diet for a period of 5 to 7 days prior to the procedure. Most obese patients have fatty and enlarged livers. Swelling on the liver makes the surgery difficult for the surgeon. Pre-operative high protein liquid diet helps to shrink the liver and makes the surgery easier for the surgeon and safer for the patient. It has been seen that patients who sincerely follow the pre-operative liquid diet, tend to achieve better weight loss results post bariatric surgery.

In the hospital

Once all the tests have been done and you are medically fit to undergo gastric banding surgery, you will need to get admitted to the hospital one evening before your scheduled surgery.
You will be fasting for 6 to 8 hours prior to the surgery.
Lap band surgery typically takes about 45 minutes to an hour to perform and is done under general anaesthesia.
You will be started on liquids within 6 to 8 hours after the surgery and will be encouraged to walk around on the same day.
If all is well, you will be discharged to go home the next day.

Mechanism of action of laparoscopic adjustable gastric banding

Laparoscopic adjustable gastric banding entails the application of an adjustable silicon band on the outer surface of the stomach. This divides the stomach into a smaller upper pouch and a larger lower pouch. The upper pouch acts as a reservoir for food and the band just below it restricts the food from going down.
Patients tend to feel full and satiated much earlier and with smaller quantities of food.
This leads to mobilization of fat stores from the body and results into gradual weight loss.
Gastric banding surgery is primarily based on the principle of restriction of food.
As the name suggests, after adjustable gastric banding, band adjustment may be needed at regular intervals. Adjustment is usually titrated as per the weight loss.

What to expect after laparoscopic gastric banding

Laparoscopic adjustable gastric banding is a day care procedure and patients can get discharged on the morning after surgery depending on their clinical condition.
At the time of gastric banding surgery, no filling is done in the band and it is left as such.
All medications including prophylaxis for venous thrombo-embolism will be explained to you before discharge.
After adjustable gastric banding, you will be on a liquid diet for about 15 days followed by soft and mashed diet for the next 15 days. You will be able to consume normal home cooked food after one month of surgery but it will be restricted in quantity.
First band adjustment is usually performed after 6 weeks. After that band adjustment is titrated as per the weight loss.
You will also need to take nutritional supplements as advised by the team. The band doesn’t really alter the gastro-intestinal anatomy and food passes in the physiological manner. Yet, there is a chance of developing nutritional deficiencies due to restricted food intake.
The team will guide you at every step about the nutritional supplementation.
It takes a few months to adjust to new eating habits. Please do not worry. We are available at all times to answer your queries.

Expected weight loss after laparoscopic adjustable gastric banding

Patients may lose up to 40 to 50% of their excess weight after adjustable gastric banding. Weight loss is dependent on many associated factors such as initial weight of the patient, age, gender, associated co-morbidities, behavioural modification made by the patient etc.
Regular band adjustment plays a major role in weight loss after adjustable gastric banding. Without adjustment, the band will not lead to much weight loss. Doctor and team will guide you about the frequency of follow up and band adjustment.
Band adjustment entails insertion or removal of fluid from the band through the port. This is done as an out-patient procedure using a special Huber needle.
Patients who embrace the lifestyle change and comply with behavioural modification guidelines as suggested by the team, tend to do better after any weight loss procedure including gastric banding surgery.
Please note that weight loss procedures must not be perceived as a short cut. High level of commitment is needed from both, the doctor and the patient. It is mandatory to follow the diet prescribed by the team and to put in atleast 30 to 45 minutes of exercise every day to achieve best results.

Improvement in co-morbidities

Gastric banding surgery leads to about 40 to 50% excess weight loss over a period of 12 to 18 months.
Gastric banding surgery also leads to a significant improvement in associated co-morbidities such as type 2 diabetes, high blood pressure, high cholesterol, obstructive sleep apnoea, gout, PCOD etc.
Improvement in the above components of metabolic syndrome eventually leads to a considerable decrease in the risk of developing heart disease.

Downsides

Over the years, adjustable gastric banding has fallen out of favour with surgeons and patients alike. Weight loss outcomes after this procedure were less than satisfactory, especially for Indian patients. Probably the high carb Indian diet is not suitable for a procedure like this. Adjustable gastric band was very popular till about 2006. Most patients who underwent gastric banding, eventually had to get the band removed and converted to another bariatric procedure such as a Roux-en y gastric bypass or a sleeve gastrectomy.
Although it is a fairly safe procedure, an adjustable gastric band can slip or erode in future. It can also lead to dilatation of the food pipe in the long term. Occasionally there can be problems at the site of port insertion also.
Patients who are allergic to silicon must not undergo this procedure.
Patients with reflux esophagitis and GERD must not undergo this procedure as this can lead to an increase in the reflux levels. Patients with SLE and previous abdominal surgeries must also not be advised to undergo this procedure. Pregnant women and patients with gastric outlet obstruction must also be excluded. Rest of the contra-indications are the same as any other bariatric surgery.

Reversibility

Adjustable gastric banding is a reversible operation.
It can also be converted to another bariatric operation such as a Roux-en y gastric bypass or a sleeve gastrectomy.
This conversion can be done either at the same time as band removal or as a second stage after 3 months. This is a clinical decision that the surgeon will take during surgery.

Cost of laparoscopic adjustable gastric banding

Laparoscopic gastric banding cost depends on the type of the band used. Laparoscopic adjustable gastric banding cost also depends on disposable equipment such as trocars, energy sources etc. This can sometimes increase the lap band surgery cost. Gastric banding surgery cost is also dependent on the number of days in the hospital, type of room selected as well as the hospital where you get operated. Doctor and the team will guide you about the adjustable gastric banding cost after assessing and evaluating all the above details.

Cost of laparoscopic gastric banding also depends on whether it is a staged procedure or being done at the same sitting. Cost of lap band surgery will also vary as per the procedure to which it is being converted to, how much disposable equipment is being used, duration of surgery, stay in the hospital etc. Cost of gastric banding surgery conversion depends on all the above factors and will be discussed on a case to case basis.

Last but not the least

We understand that by taking the decision to undergo this surgery, you have taken a major life decision. This decision will propel you into a better and healthier life. We are your equal partners in this journey and having a positive frame of mind is extremely important before taking this step. We are here to take care of you and solve your tiniest query. We urge you to stay positive, because your body hears everything that your mind says.

“The preservation of health is easier than the cure of disease.”