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INDICATIONS

Gastric banding involves the placement of a prosthetic band around the upper stomach, to create a small gastric pouch similar to gastric bypass, but without the need for transection or anastomosis of the gastrointestinal tract. Surgeons in Europe and Australia have accumulated significant experience with gastric banding over the past three decades. As data accumulate, it has become clear that weight loss and metabolic disease remission outcomes after gastric banding do not match those associated with gastric bypass or sleeve gastrectomy, and long-term morbidity requiring band explant may exceed 50%. Nonetheless, peri-operative major morbidity and mortality associated with gastric banding is 5–10-fold lower than that associated with gastric bypass and sleeve gastrectomy. As such, gastric banding, while waning in use, remains a component of the bariatric surgery armamentarium. Gastric band patients often require multiple fills of the band reservoir before weight loss begins, and they typically achieve maximal weight loss after 2 to 5 years. Patients who have difficulty with frequent postoperative visits may not be ideal band candidates, nor are patients who do not understand the postoperative care involved in gastric banding. Candidacy for gastric banding is dictated by National Institutes of Health (NIH) criteria for bariatric surgery and require patients to have a body mass index of at least 40, or at least 35 with a serious obesity-related comorbidity. In addition, patients should demonstrate a full understanding of the advantages and disadvantages of gastric banding, and a willingness to comply with postoperative care.

PREOPERATIVE PREPARATION

Candidates for gastric banding should undergo a preoperative upper gastrointestinal series to identify the presence of hiatal hernia. Small hiatal hernias can be repaired at the time of gastric band placement. The presence of a large hiatal hernia, however, although not an absolute contraindication to gastric banding, should be considered carefully in a surgeon’s early experience, because repair of such hernias in obese patients can be technically challenging. Patients with symptoms of gastroesophageal reflux disease should undergo 24-hour esophageal pH testing. Data are sparse, but most series report improvement of gastroesophageal reflux disease after gastric banding, although a minority of studies demonstrates worsening of symptoms. Similarly, patients with symptoms of esophageal motility disorders should undergo preoperative esophageal manometry. The presence of significant esophageal dysmotility should be considered a relative contraindication to gastric banding. Despite a paucity of data studying the effect of gastric banding on esophageal motility, concerns remain regarding the long-term effects of gastric banding on patients with severe esophageal dysmotility.

Patients should continue all preoperative medications until the morning of surgery, with the exception of aspirin, nonsteroidal anti-inflammatory agents, warfarin, or heparin. Mechanical bowel preparation is not necessary.

ANESTHESIA

General anesthesia with complete neuromuscular blockade is required for laparoscopic gastric banding. Intravenous antibiotics directed against skin flora are often administered, although no data exist to support this practice. Aggressive prophylaxis of nausea prior to emergence from ...

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