Gastric Dumping Syndrome

Morbid obesity, which correlates with a body mass index (BMI) (weight [kilograms]/height [[meters].sup.2]) of 40 or higher, is a chronic, intractable disease that, if left untreated, results in increased morbidity and mortality and a decreased life span. (1) More than 97 million people in the United States are either overweight or obese, (2) resulting in health care costs that approach $70 billion per year. (3) According to the Surgeon General's recent "call to action," the number of people who are overweight or obese have reached nationwide epidemic proportions. In 1999, an estimated 61% of adults in the United States were overweight, as were 13% of children and adolescents. (4) Traditional nonsurgical weight loss methods that attempt to decrease weight through dietary and behavioral interventions often result in disappointing outcomes with a high rate of relapse. (5) Surgery to treat morbid obesity has been recognized by the National Institutes of Health (NIH) as an approach for well-informed and motivated patients for whom the surgical risks are acceptable. (6)

Until recently, surgical options were limited to procedures performed through an open incision (Table 1). These procedures permanently alter the anatomy of the digestive tract (Figure 1) by stapling or bypassing the stomach and a portion of the small intestine or a combination of these procedures. This can result in long-term morbidities, including macronutrient and micronutrient deficiencies and, in rare instances, death. (7) The two surgical weight loss procedures most commonly performed in the United States for morbid obesity have been the Roux-en-Y gastric bypass and vertical banded gastroplasty. (8)

[FIGURE 1 OMITTED]

The Roux-en-Y gastric bypass is both restrictive (ie, limits the amount of solid food the patient is able to ingest) and malabsorptive (ie, decreases intestinal absorption) (Figure 2). During this procedure, staples are used to construct a small, restrictive upper gastric pouch, which then is anastomosed directly to the small bowel, bypassing most of the stomach and some of the small intestine. (9) Vertical banded gastroplasty is a restrictive procedure in which staples are used to make a small stomach pouch; however, no rerouting of the digestive tract occurs (Figure 3). (10)

[FIGURE 2-3 OMITTED]

In June 2001, the US Food and Drug Administration (FDA) approved an adjustable gastric banding system for use in the surgical treatment of morbid obesity (Figure 4). This approval was received after clinical trials were conducted through-out the country between 1996 and 2001. Results of these studies, as well as those of other studies conducted throughout the world, have demonstrated the safety and efficacy of adjustable gastric banding. (11) The gastric band, which is adjustable and reversible if medically indicated, is placed laparoscopically and does not alter the normal anatomy. Since 1993, more than 80,000 adjustable gastric banding procedures have been performed worldwide. (12)

[FIGURE 4 OMITTED]

HISTORY OF GASTRIC BANDING

The concept of stomach banding to treat obesity originated in 1976, when Lawrence Wilkinson, MD, used a strip of synthetic polypropylene mesh as the band, resulting in a reduction of the gastric reservoir. (13) Since that time, variations on this procedure using synthetic polyethylene terephthalate and polytetrafluoroethylene vascular grafts have been performed. (14)

The first adjustable silicone gastric band was introduced in the 1980s by Lubomyr Kuzmak, MD, who added an inflatable portion to the band attached via a tube to an access port that was implanted subcutaneously. (15) This configuration allowed for postoperative adjustments of the size of the opening (ie, stoma) between the upper and lower stomach reservoirs by the addition or removal of saline via a needle inserted into the access port. With the advancement of laparoscopic surgical techniques and a growing demand for an adjustable gastric band that could be inserted without the need for open surgery came the introduction of laparoscopic adjustable gastric banding. Today, the laparoscopic adjustable gastric banding system includes a slip-through buckle with self-locking closure system and a calibration tube to facilitate sizing of the pouch at the time of placement.

RISKS AND BENEFITS

Morbid obesity is associated with serious medical problems, such as type 2 diabetes, hypertension, heart disease, gastroesophageal reflux disease, sleep disorders, and asthma (Table 2). (16) Studies show that even a moderate weight loss after laparoscopic adjustable gastric banding surgery can result in improvements in all of these conditions. (17) Numerous studies show that weight loss following laparoscopic adjustable gastric banding surgery significantly improves patients' quality of life physically, socially, and psychologically. (18) The risks of this surgery are outweighed by the benefits it provides.

Risks. Surgeons report fewer perioperative complications following laparoscopic gastric banding surgery than with other forms of surgery for obesity. (19) The most commonly reported postoperative complication associated with laparoscopic gastric banding is stomach pouch enlargement, which usually is associated with slippage of the stomach wall through the band. (20) The incidence of this complication, however, has been dramatically reduced with surgical technique modifications. One researcher reported a reduction in stomach slippage from 30% in his first 50 patients to 2.5% in a later group of 200 patients. (21) There also have been repons of erosion of the band through the stomach tissue; a large European study showed an erosion rate of 1%. (22) Complications related to the access port and tubing also have been reported, including movement or tilting of the access port, leaking or broken tubing, or infection at the access port site. Better placement and fixation techniques have resulted in fewer of these complications. (23) Rarely, stomach perforation may occur during surgery. (24)

Benefits. Laparoscopic adjustable gastric banding, unlike vertical banded gastroplasty and Rouxen-Y gastric bypass, involves no stapling of the stomach, no cutting or opening of the stomach wall, and no permanent alteration of the gastrointestinal (GI) tract. Should it be necessary to remove the band, normal stomach anatomy can be restored. (25) Bleeding or leaking at GI surgical junctions is not a concern, nor are long-term nutrient deficiencies and dumping syndrome because the GI tract is left intact. Dumping syndrome is defined as a symptom complex usually occurring with sweet or sugar intake after a procedure that obliterates or bypasses the function of the pyloric sphincter. The ability to place a gastric band laparoscopically decreases the invasiveness of the procedure, resulting in fewer postoperative complications, shorter hospitalization, and quicker recovery time for patients. (26) The ability to adjust the size of the stoma postoperatively to address patient nutrition needs and customize weight loss is recognized as a significant advantage of an adjustable gastric band. (27)

A MULTIDISCIPLINARY APPROACH TO WEIGHT MANAGEMENT

Patient evaluation for laparoscopic adjustable gastric banding surgery should be performed by a multidisciplinary weight management team. This weight management team should consist of a group of specially trained individuals with expertise in obesity and sensitivity to the specific needs of patients who are morbidly obese. These team members may vary based on individual practice needs and availability of staff members. Individuals dedicated to the team process who share the same philosophy regarding obesity as a chronic disease requiring lifelong treatment and believe in the efficacy and safety of surgical intervention are critical to attaining successful patient outcomes. A proposed model for an ideal multidisciplinary weight management team would consist of a bariatfic primary care physician, bariatric surgeon, bariatric nurse practitioner, registered dietitian, exercise physiologist, and psychiatric nurse practitioner. Patients meet individually with each team member for assessment and counseling.

Activity and fitness therapy. An initial consultation and evaluation with a health fitness instructor is the first step in developing an individual activity plan for all patients. Customized to the medical and lifestyle considerations of each patient, this intervention seeks to establish a realistic activity plan. Moderate changes in activity level and lifestyle can increase flexibility, which allows greater range of motion, decreases the chance of injury and soreness, and provides better balance. Increased cardiovascular endurance improves cardiac and pulmonary function and total functional aerobic capacity. An individualized activity plan clearly will identify the type (eg, walking, swimming, dancing), intensity, duration, and frequency of exercise appropriate for each patient.

Behavioral therapy. A comprehensive psychiatric evaluation is conducted on all patients preoperatively by a psychiatric nurse practitioner. Table 3 provides a list of some of the issues that the psychiatric nurse practitioner should identify during the mental status examination. A careful psychiatric evaluation identifies patients who may be inappropriate candidates for surgery or who may need specific pharmacological or therapeutic interventions before or after surgery to optimize favorable outcomes. Contraindications for bariatric surgery may include

* active substance abuse other than food, such as drugs or alcohol;

* certain psychiatric disorders (eg, active psychosis, untreated or unremitting depression); and

* previously demonstrated noncompliance with medical or psychiatric care.

Indicators of poor outcome include

* chaotic lifestyle,

* inability to care for oneself,

* lack of commitment (eg, failure to keep scheduled appointments),

* lack of motivation,

* lack of social support (eg, resistance or opposition from family members or friends),

* poor insight or judgment, and

* social isolation.

Individuals with unrealistic expectations who regard surgery as a magic cure rather than a tool requiring their diligence and involvement likely will have disappointing outcomes.

Medical nutrition therapy. Bariatric surgery candidates meet individually with a registered dietitian for a comprehensive nutritional evaluation. Based on medical history and actual weight, the dietician determines patients' caloric and nutrient needs. The dietician also assesses patients' food preferences, frequency of food and meal intake, and behavior-related food consumption. The dietician then develops special meal plans tailored to patients' eating habits, lifestyle, budget, and nutrient needs. For patients with special dietary needs, the physician prescribes medical nutrition therapy using liquid formulas, dietary supplements, and vitamin therapy. Patients attend mandatory nutrition classes where healthy eating behaviors (eg, eating slowly, chewing thoroughly), food selection (eg, nutrient-dense vs comfort foods), portion size, and menu planning are taught.

Team approach. Team conferencing following completion of the evaluation process can help identify individual patient needs and appropriateness for surgery. Individual and group counseling should be encouraged and available to all patients, both preoperatively and postoperatively. Attendance at support group meetings facilitated by various team members are mandated preoperatively and encouraged postoperatively, thus providing patients with an informal social network where a sense of commitment, belonging, and acceptance can be fostered through the sharing of common experiences.

PATENT SELECTION

The single most important predictor of a favorable outcome following any bariatric procedure is proper patient selection. Individuals being considered for weight loss surgery must meet nationally accepted criteria (Table 4). (28) Surgery should be considered adjuvant therapy and must be part of a multidisciplinary approach. Patient selection is a process, usually taking several weeks to months, during which patients are evaluated, educated, and counseled in preparation for a surgical procedure that requires lifelong behavioral changes. Factors, such as age, fat distribution, and food preferences need to be considered in patient selection.

Age. No specific guidelines exist with regard to age-appropriateness for bariatric surgery. The adjustable gastric band currently available in the United States has been approved by the FDA for use in those individuals who are 18 years of age or older. (29) Where intellectual and emotional maturity have been demonstrated, younger patients might be considered. Where the risk-benefit ratio is favorable, older adult patients who meet all other criteria also may be considered appropriate for laparoscopic adjustable gastric banding. This decision often will be based on quality-of-life issues for older adult patients rather than on increased longevity. Laparoscopic gastric banding is nonmutilating, minimally invasive, adjustable, and reversible; therefore, in the future, this procedure may position itself as a better option for younger and older patients.

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)

PATIENT EVALUATION PROCESS

Patient evaluation involves a four-step process. After obtaining a health history during which the patient describes his or her weight history, the patient undergoes a physical examination followed by laboratory tests.

Medical evaluation. A comprehensive health history should be obtained early in the evaluation process. The scope and focus of this history should be designed to identify any comorbid conditions and to assess for the acuity, stability, and complications of these comorbidities. A complete review of systems helps identify problems that the patient has not mentioned. Areas of particular importance to bariatric surgical candidates are symptomatology indicative of undiagnosed medical illnesses such as heart disease, diabetes, thyroid disease, polycystic ovarian syndrome, and obstructive sleep apnea. The Epworth Sleepiness Scale screens for patients who will require polysomnography for the diagnosis of suspected sleep apnea. (36) A family history combined with other risk factors helps determine the need for additional preoperative diagnostics.

Weight history. Most patients considering weight loss surgery have a long-standing history of obesity, often dating back to their childhoods. Patients typically have had a lifelong struggle with failed weight loss attempts, feel hopeless after having exhausted all other treatment modalities, and feel a sense of urgency to proceed with surgery now that it has become a viable option. It is not uncommon for patients to feel guilt or shame for having a disease that society has associated with a lack of willpower and laziness. Details of the patient's weight history (Table 5) should be carefully determined and documented because this information often is required by the insurance carrier for predetermination of benefits.

Physical examination. A thorough physical examination should be conducted. The patient should be evaluated carefully for any signs of heart, lung and endocrine disease. The examiner should pay particular attention to the oropharynx, body fat distribution, and abdominal girth. A crowded oropharynx often is a predictor of sleep apnea and a potentially difficult intubation. The presence of android vs gynoid fat distribution also should be determined. Android (ie, upper body or central obesity) refers to a fat distribution usually found in men. Gynoid (ie, pear-shaped) refers to a female type of fat distribution. These individuals are said to have gynoid obesity. Either type of fat distribution can occur in either sex. Android obesity, excessive abdominal girth, and the presence of hepatomegaly, usually due to a fatty liver, are all predictors of technical difficulty during surgery. Common findings on physical examination of patients who are morbidly obese include a crowded oropharynx, distant cardiac and breath sounds, striae, intertrigo (ie, erythematous condition of skin folds), tibial edema, and signs of venous insufficiency.

Diagnostic workup. A complete blood count, comprehensive metabolic panel, thyroid stimulating hormone test, lipid profile, and urinalysis should be obtained on all patients preoperatively. Measuring glycosylated hemoglobin in patients with diabetes evaluates glycemic control and the need for specific interventions preoperatively. An electrocardiogram, ultrasound of the abdomen, upper GI series, and pulmonary function test also are performed routinely. Common findings in patients who are morbidly obese include

* restrictive lung disease,

* fatty infiltration of the liver and cholelithiasis, and

* hiatal hernia and gastroesophageal reflux disease.

Based on the health history and physical examination findings, tests such as polysomnography, nuclear stress testing, echocardiography, and endoscopy may be indicated. Cardiac, pulmonary, and endocrine consultations should be requested based on individual patient needs. Esophageal manometry and pH monitoring also may be considered when alteration in esophageal motility is suspected.

PERIOPERATIVE CONSIDERATION

Patients undergoing bariatric surgery need special consideration perioperatively. Their large body habitus and associated serious comorbidities make patients who are morbidly obese high-risk surgical candidates who require careful planning and implementation of patient care.

Equipment Facilities in which surgical procedures for the treatment of morbid obesity are performed must have equipment that can accommodate patients who weigh more than 350 lbs (159 kg). The OR bed and stretchers must have the capacity to accommodate patients who are super obese (eg, up to 770 lbs [350 kg]) and be able to rotate and tilt to gain adequate exposure. Most standard hospital beds, OR beds, commodes, scales, and wheelchairs are not adequate; however, there are a number of companies from whom these pieces of equipment can be purchased or rented. Extra-large patient gowns and blood pressure cuffs require a small investment by the hospital and should be stocked routinely. In addition to the standard equipment required for a laparoscopic procedure, a high-flow insufflator (ie, 20 L per min), extra-long trocars, and a retractor strong enough to atraumatically retract a large, heavy liver should be available. (37)

Positioning the patient is challenging, so additional padded safety belts, gel or foam pads, and large elastic bandages are needed to prevent injury and movement of the extremities during surgery. This patient population has a higher incidence of venous stasis disease, placing them at increased risk for deep vein thrombosis, and they should have proper-fitting pneumatic sequential compression devices applied in the OR.

Anesthesia. The preoperative anesthesia assessment should include

* a review of the patient's medical history;

* careful physical examination;

* laboratory screening;

* evaluation of cardiac size, lung pathology, medications; and

* a detailed assessment of the upper airway.

Rapid sequence induction with crycoid pressure is the preferred method for intubation. (38) Sodium citrate and [H.sub.2] antagonists are given preoperatively to increase gastric pH and block acid production. These are administered because of the increased incidence of gastroesophageal reflux disease and hiatal hernia in this patient population, which places them at higher than normal risk for aspiration pneumonitis.

Positioning the patient and surgical team. Favorable outcomes for laparoscopic procedures are dependent on a well-organized surgical team. Proper patient positioning can either facilitate the procedure or increase the level of difficulty.

Laparoscopic gastric banding generally is performed with the patient in a modified lithotomy position (Figure 5). After the anesthesia care provider has induced the patient under general anesthesia, the circulating nurse inserts a Foley catheter and places intermittent pneumatic sequential compression devices on the patient's legs. The circulating nurse and several other surgical team members cooperatively place the patient's legs in well-padded, bootlike, low-lithotomy stirrups. They ensure that the patient's hips and knees are not hyperextended. The anesthesia care provider and circulating nurse either tuck the patient's arms at his or her sides or extend them at less than a 90-degree angle on well-padded OR bed armboards. When positioning patients who are obese, surgical team members take care to ensure that the patient's extremities are adequately supported and secured to prevent nerve injury and movement during the surgical procedure.

[FIGURE 5 OMITTED]

The surgeon stands between the patient's spread legs, and the RN first assistant stands on the patient's left side. Some ORs are equipped with booms suspended from the ceiling that can accommodate the laparoscopic monitor. If these are not available, the circulating nurse positions the monitor as close as possible to the left or right side of the patient's head.

Intra-abdominal access and trocar placements. Laparoscopic intra-abdominal access can be achieved by either an open technique using the Hasson cannula or a closed technique using the Verres needle. The surgeon determines which of the two methods to use to enter the abdominal cavity. One of the more common sites for access is the umbilicus; however, alternate site access and insufflation at the left upper quadrant or left subcostal region is possible. When using a left subcostal approach, as the Verres needle passes through the anterior and posterior fascia and the peritoneum, three distinct clicks should be audible.

It also is imperative to perform a saline drop test, which helps ensure safe passage into the peritoneum without injury to any solid or viscous organs or vascular structures. When the surgeon has inserted the Verres needle using the three-click method, he or she attaches a 10-mL syringe to the Verres needle and aspirates back. Withdrawing any fluid or material, such as blood, intestinal content, stool, or urine indicates that the needle has punctured an organ and requires remedial action. If no fluid or material is withdrawn, the surgeon drops several milliliters of saline into the Verres needle. The saline flowing easily through the needle confirms that it is safely in the peritoneal cavity.

The surgeon achieves pneumoperitoneum to a level of 15 mm Hg. He or she then strategically places five or six trocars that vary in diameter (ie, 5 mm, 10 mm, 12 mm) using laparoscopic vision. One 15-mm trocar also is placed for introduction of the laparoscopic adjustable gastric band into the peritoneal cavity (Figure 6). The site of the 15-mm trocar usually is the largest incision so the surgeon can place the laparoscopic adjustable gastric banding system access port subcutaneously and anchor it to the anterior rectus fascia.

[FIGURE 6 OMITTED]

Surgical procedure. Three different dissection techniques can be used when inserting the gastric banding system. In all three techniques, an oral-gastric calibration tube with an inflatable balloon is inserted into the stomach to facilitate selection of the initial dissection starting point.

Perigastric technique. Using the perigastric technique, the surgeon begins dissection directly on the lesser curve at the equator of the calibration-tube balloon. He or she completes the dissection behind the stomach toward the angle of His, avoiding the lesser sac. The surgeon places gastrogastric sutures anteriorly to secure the band (Figure 7).

[FIGURE 7 OMITTED]

Pars flaccida technique. Using the pars flaccida technique, the surgeon starts dissection directly lateral to the equator of the calibration-tube balloon in the avascular space of the pars flaccida. After seeing the caudate lobe of the liver, he or she continues blunt dissection until the right crus muscle is seen, followed immediately by the left crus muscle over to the angle of His (Figure 8).

[FIGURE 8 OMITTED]

Two-step technique. Some surgeons use a two-step technique, which begins with the pars flaccida technique, followed by a second dissection at the equator of the balloon near the stomach until the perigastric dissection intercepts the pars flaccida dissection. The band then is placed from the angle of His through to the perigastric opening. (39) The band is pulled around the stomach and locked into place (Figure 9). The access port is connected externally to the banding system tubing and placed in the left rectus muscle or a similar location, allowing the port to be accessed percutaneously to modify the fill volume of the band yet be inconspicuous to the patient on a day-to-day basis, even after significant weight loss occurs.

[FIGURE 9 OMITTED]

POSTOPERATIVE CARE

After the surgery is completed, surgical team members transfer patients directly from the OR bed to the postoperative bariatric bed, avoiding an additional transfer to the postanesthesia stretcher. Postanesthesia care unit (PACU) nurses consider airway maintenance to be of utmost importance because patients who are morbidly obese often have compromised airways secondary to excessive soft tissue and large neck circumference. Patients with obstructive sleep apnea treated at home with nasal continuous positive airway pressure should bring their specially fitted equipment to the hospital on admission for use in the PACU. Pain management in the early postoperative period may require the use of narcotics, further impairing respiratory status. The nurses administer anti-inflammatory medications intramuscularly or per rectum rather than using narcotics, if possible.

Patients are transferred to the medical/surgical unit where nurses ensure they receive nothing by mouth for several hours after the procedure, after which nurses can initiate ice chips and sips of clear liquids, progressing to full liquids before discharge. Nurses encourage early mobilization, assisting patients out of their beds to a chair within hours after surgery and ambulating them shortly thereafter. The nurses anticipate that patients may experience shoulder pain postoperatively because of carbon dioxide, which is used to obtain a pneumoperitoneum, pressing against the diaphragm. An esophogram usually is performed on the first post-operative day to assess band position and stoma patency. Nurses educate patients preoperatively about the importance of participating in their post-operative care, which can have a profound effect on preventing pulmonary and thromboembolic complications. Patients usually are discharged home within 24 hours of surgery.

DISCHARGE INSTRUCTIONS

Nurses are instrumental in ensuring that patients are well informed about how to perform self-care when they arrive home by explaining the physician's discharge instructions. Activity, diet, and medication instruction are important pieces of information nurses provide patients before discharge.

Activity. Nurses advise patients to avoid driving for one week. Additionally, nurses instruct patients to avoid lifting anything heavy or participating in strenuous activity for two weeks postoperatively. Nurses encourage patients to perform other aerobic activities, such as walking, as soon as it is comfortable.

Diet. Table 6 describes the diet that the patient must follow immediately after surgery, during the following weeks, and thereafter for as long as the gastric band is in place. Dieticians explain that the patient must consume a full liquid diet for the first three weeks postoperatively, and that to ensure adequate protein intake, the patient may need to consume commercially prepared protein drinks. Avoiding regular foods during this time prevents distention of the small upper gastric pouch and dietary indiscretions that cause vomiting, both of which may predispose the patient to band slippage. Dieticians describe advancing the diet during the second month. Pureed foods are recommended, and by the third month, patients who have undergone laparoscopic adjustable gastric banding can progress to soft foods. At all times, foods must be eaten slowly, chewed thoroughly or pureed, and consumed in small portions. Fibrous and dry foods should be avoided. Dietary indiscretions may result in symptoms, such as epigastric discomfort and vomiting.

Dieticians instruct patients to

* avoid eating and drinking at the same time,

* keep portion size to less than 3/4 of a cup, and

* avoid drinking carbonated liquids and alcoholic beverages.

To ensure adequate hydration and prevent pouch distention, the patient should be instructed to consume adequate fluids 90 minutes after a meal until 15 minutes before the next meal.

Medications. A chewable multivitamin should be taken daily, and H2 antagonists often are prescribed prophylactically during the first month after surgery. Most patients require only mild analgesics, such as acetaminophen, for the first several days after surgery. It generally is good practice to avoid the use of anti-inflammatory medications following gastric restrictive surgery because of the potential for gastric ulcer formation. Patients are instructed to avoid large pills and substitute liquid preparations or smaller tablets when possible.

BAND ADJUSTMENTS

The percutaneous adjustability of the stoma size is one of the most important features of the gastric banding system, which allows for customization of the degree of restriction over time. The band is adjusted by injecting or removing saline via the self-sealing access port using a special noncoring needle (ie, Huber tip). In some cases, radiological assistance is used to locate the port for the adjustment. In other cases, it is possible to palpate and locate the access port without x-ray assistance. (40)

To determine whether the patient is ready for a band adjustment, the weight management team considers the amount of saline already in the patient's band and assesses his or her

* food portion size or the amount of food that can be eaten comfortably;

* level of satiety;

* symptoms, such as heartburn, regurgitation, or vomiting; and

* weight loss.

Other issues regarding the patient's health that affect his or her nutritional needs, such as pregnancy or significant concurrent illnesses, also should be taken into consideration.

An optimal rate of weight loss is approximately 1 lb to 2 lbs per week. Generally, no adjustments are necessary if this is being achieved. If weight loss is slower than 1 lb per week, the weight management team should consider inflating the band slightly (ie, 0.2 mL to 1.0 mL saline) in concert with assessing what and how the patient is eating. The more the band is inflated, the smaller the stoma is, which makes it more restrictive. Slow weight loss or weight gain can be a result of a band being too tight, which causes difficulty consuming most solid foods; therefore, the patient will exist on foods that go down easily, such as high-calorie soft carbohydrates and liquids (eg, cream soups, ice cream). The patient also may eat past the band by consuming these high-calorie liquids rather than eating healthy solid food. Being able to eat too much also can be caused by an enlargement of the gastric pouch, either due to gastric slippage or pouch dilatation from chronic over-eating. A brief, limited barium swallow examination can confirm if the pouch is small or enlarged. The weight management team should determine whether a significant increase in food intake is reported and the band still is inflated.

SUMMARY

Morbid obesity is a serious and increasing health problem. The laparoscopic adjustable gastric band has proven to be an effective, nonmutilating, and reversible surgical option for treating morbid obesity. Numerous studies show that significant weight loss (ie, 54% to 75% of excess body weight) occurs after gastric banding surgery, and that even modest weight loss (ie, 10% of excess body weight) in people who are morbidly obese results in a significant improvement in health for patients with comorbidities, such as gastroesophageal reflux disease, heart disease, high blood pressure, obstructive sleep apnea, and type 2 diabetes. (41) Additionally, patients' physical, social, and psychological quality of life has been shown to improve dramatically.

An important factor in the success of laparoscopic adjustable gastric banding is careful patient selection. Patients being considered for the surgery must meet nationally accepted criteria and should undergo comprehensive evaluation, education, and counseling in preparation for a procedure that requires lifelong behavioral changes. A multidisciplinary approach to patient management is crucial for success.

Patients undergoing bariatric surgery need special consideration perioperatively. Their large body habitus and comorbidities render them high-risk surgical candidates requiring thorough planning and implementation of care. During surgery, the patient must be positioned carefully, equipment must be adequate, and special considerations may be necessary for the administration of anesthesia.

Comprehensive long-term patient follow up is very important after gastric banding. Achieving and maintaining weight loss is a lifelong process. It is important that patients comply with postoperative dietary restrictions, including the amount and types of foods ingested and acquiring new dietary habits. Periodic adjustments to the size of the stoma opening may be necessary. The ability to perform stoma adjustments in the office to address patient nutrition needs and customize weight loss is recognized as a significant advantage of the adjustable gastric banding procedure.

Examination

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING FOR MORBID OBESITY

1. Laparoscopic adjustable gastric banding may produce -- % to -- % excess weight loss at three years.

a. 38/58

b. 42/64

c. 54/75

d. 66/85

2. All of the following are risks of adjustable gastric banding except

a. stomach pouch enlargement.

b. band slippage or erosion of the band through the stomach.

c. port movement or tubing leakage.

d. foul smelling stools and gas.

3. Problems that can be avoided by laparoscopic adjustable gastric banding rather than the traditional bypass procedures include all of the following except

a. long-term nutrient deficiencies.

b. stomach pouch enlargement.

c. inability to restore normal stomach anatomy.

d. bleeding or leaking at gastrointestinal surgical junctions.

4. The single most important predictor of a favorable outcome following any bariatric procedure is preoperative body mass index.

a. true

b. false

5. Measuring -- in patients with diabetes evaluates glycemic control and the need for specific interventions preoperatively.

a. cholesterol and lipoprotein fractionation

b. serum osmolality

c. glycosylated hemoglobin

d. agglutination

6. The preferred method of intubation is

a. routine induction.

b. awake intubation with fiberoptic assistance.

c. preoxygenation before awake intubation.

d. rapid sequence induction and crycoid pressure.

7. Laparoscopic gastric banding generally is performed with the patient in a -- position.

a. prone

b. modified lithotomy

c. supine

d. right lateral decubitus

8. The adjustable gastric banding access port is placed subcutaneously and anchored to the

a. anterior rectus fascia.

b. inferior rectus medialis.

c. posterior rectus fascia.

d. superior rectus medialis.

9. Using the -- technique, the surgeon begins dissection directly on the lesser curve at the equator of the calibration-tube balloon. He or she completes the dissection behind the stomach toward the angle of His, avoiding the lesser sac.

a. perigastric

b. two-step

c. pars flaccida

d. fenestrated

10. Using carbon dioxide to obtain a pneumoperitoneum may cause postoperative

a. obstructive sleep apnea.

b. shoulder pain.

c. laryngeal spasm.

d. dumping syndrome.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. AORN recognizes these activities as continuing education for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.

Table 2 DISEASES ASSOCIATED WITH MORBID OBESITY (IN ORDER OF IMPORTANCE) (1)

Type 2 diabetes mellitus

Degenerative joint disease--risk of developing arthritis is increased by 9% to 13% for every 2-lb increase in weight

Hypertension--twice as common in adults who are obese than in those who are of normal weight

Coronary artery disease

Gallbladder disease

Certain types of cancer (eg, breast, colon, gallbladder, kidney, prostate, uterine)

Gastroesophageal reflux disease

Pulmonary disease (eg, sleep apnea, asthma)

Psychological problems (eg, depression)

Infertility

High-risk pregnancy

Stress incontinence

NOTE

(1.) J B Dixon, M E Dixon, P E O'Brien, "Quality of life after lap-band placement: Influence of time, weight loss, and comorbidities," Obesity Research 9 (November 2001) 713-721.

Table 3 ISSUES TO EVALUATE IN THE PSYCHIATRIC ASSESSMENT

Availability of support systems

Current living situation

Family members' and friends' attitudes toward the proposed surgical intervention

History of psychiatric problems, type and effectiveness of treatment, and need for psychotropic medications

History of physical or sexual trauma, rape, or suicide attempts

Personal and social history

The patient's general

* Affect

* Appearance

* Attitude

* Behavior

* Cognitive function and content of thought

* Eating patterns and history of binge eating, fasting

* Facial expressions and ability to make eye contact

* Insight, judgement, and expected outcomes

* Vomiting or use of laxatives or diuretics for the purpose of weight loss

* Exercise patterns

* Feelings of guilt, disgust, or depression associated with overeating

* Mood

* Speech patterns

* Weight fluctuations

Effect of weight on

* Relationships

* Self-esteem

* Work

Table 4 PATIENT SELECTION CRITERIA FOR OBESITY SURGERY (1)

Body mass index (BMI) of 40 or higher

BMI of 35 or higher with comorbidities

Long-term history of obesity

Multiple unsuccessful attempts at nonsurgical methods of weight loss

Ability to comply with dietary and behavioral changes as recommended by the weight management team

NOTE

(1.) "Prevalence of overweight and obesity among adults: United States, 1999-2000," National Center for Health Statistics, Centers for Disease Control and Prevention, http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm (accessed 7 March 2003).

The author wishes to acknowledge John Dixon, MD, Nick Gabriel, DO, Deborah Cosgrove, NPP, and Lisa Gentile for their contributions to this article.

NOTES

(1.) "Overweight and obesity: The Surgeon General's call to action to prevent and decrease overweight and obesity," Office of the Surgeon General, http://www.surgeongeneral.gov/topics/obesity (accessed 7 March 2003); "Prevalence of Overweight and Obesity Among Adults: United States, 1999-2000," National Center for Health Statistics, Centers for Disease Control and Prevention, http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm (accessed 7 March 2003).

(2.) "Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--executive summary: Evidence-based guidelines," National Institutes of Health, http://www.nhlbi.nih.gov/guidelines/obesity/sum_evid.htm (accessed 7 March 2003).

(3.) G A Colditz, "Economic costs of obesity and inactivity," Medicine and Science in Sports and Exercise 31 (November 1999) S663-667.

(4.) "Overweight and obesity: The Surgeon General's call to action to prevent and decrease overweight and obesity."

(5.) P M Benotti, R A Forse, "The role of gastric surgery in the multidisciplinary management of severe obesity," American Journal of Surgery 169 (March 1995) 361-367.

(6.) National Institutes of Health, "Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report," Obesity Research 6 (November 1998) 51S-209S; B M Balsiger, L Luae-deLeon, M G Sarr, "Surgical treatment of obesity: who is an appropriate candidate?" Mayo Clinic Proceedings 72 (June 1998) 551-558.

(7.) G B Cadiere et al, "Laparoscopic gastroplasty (adjustable silicone gastric banding)," Seminars in Laparoscopic Surgery 7 (March 2000) 55-65.

(8.) B L Fisher, A E Barber, "Gastric bypass procedures," in UPDATE: Surgery for the Morbidly Obese Patient, ed M Deitel, G S Cowan, (Toronto: FD Communications, Inc, 2000) 125-129; B Fisher, P Schauer, "Medical and surgical options in the treatment of severe obesity," The American Journal of Surgery 184 suppl (December 2002) 9S-16S.

(9.) Fisher, Barber, "Gastric bypass procedures," 125-129; K Jones, "Twelve years and 1563 Roux-en-Y gastric bypass procedures: Is the laparoscopic adjustable gastric band truly the 'method of choice in obesity'?" Obesity Surgery 9 (April 1999) 125; R E Brolin, M Leung, "Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity," Obesity Surgery 9 (April 1999) 150-154.

(10.) B E Terry, "Gastroplasty procedures, particularly vertical banded gastroplasty," in UPDATE: Surgery for the Morbidly Obese Patient, ed M E Diesel, G E Cowan (Toronto: FD Communications, Inc, 2000) 125-129; E Naslund, "Seven year results of vertical banded gastroplasty for morbid obesity," European Journal of Surgery 163 (April 1997) 281-286.

(11.) P O'Brien et al, "The Lap-Band provides effective control of morbid obesity--a prospective study of 350 patients followed for up to 4 years," Obesity Surgery 8 (August 1998) 398-399; M Belachew et al, "Laparoscopic adjustable gastric banding," World Journal of Surgery 22 (September 1998) 955-963; J Dargent, "Laparoscopic adjustable gastric banding: Lessons from the first 500 patients in a single institution," Obesity Surgery 9 (October 1999) 446-452.

(12.) J Dargent, "Pouch dilatation and slippage after adjustable gastric banding: Is it still an issue?" Obesity Surgery 13 (February 2003) 111-115; P O'Brien, J Dixon, "Weight loss and early and late complications--The international experience," The American Journal of Surgery 184 (December 2002) 42S-45S.

(13.) L H Wilkinson, "Reduction of gastric reservoir capacity," American Journal of Clinical Nutrition 33 (February 1980) 515-517; L I Kuzmak, Gastric Banding in Surgery for the Morbidly Obese Patient (Philadelphia: Lea & Febiger, 1989) 225-259.

(14.) Wilkinson, "Reduction of gastric reservoir capacity," 515-517.

(15.) Fisher, Schauer, "Medical and surgical options in the treatment of severe obesity," 9S-16S.

(16.) "Overweight and obesity: The Surgeon General's call to action to prevent and decrease overweight and obesity;" T Gordon, W B Kannel, "Obesity and cardiovascular disease: The Framingham study," Clinics in Endocrinology and Metabolism 5 (July 1976) 367-375.

(17.) R Alvarez-Cordero, "Laparoscopic gastric banding: Initial two year experience," Obesity Surgery 8 (August 1998) 360; J B Dixon, P E O'Brien, "Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding," Diabetes Care 25 (February 2002) 358-363; J B Dixon, P E O'Brien, "Gastroesophageal reflux in obesity: The effect of Lap-Band placement," Obesity Surgery 9 (December 1999) 527-531; J B Dixon, L Chapman, P E O'Brien, "Marked improvement in asthma after LAP-BAND[R] surgery for morbid obesity," Obesity Surgery 9 (August 1999) 385-389; J B Dixon, L M Schachter, P E O'Brien, "Sleep disturbance and obesity: Changes following surgically induced weight loss," Archives of Internal Medicine 161 (January 2001) 102-106; J Heimbucher, Laparoscopic Gastric Banding: Effects of Excess Weight Reduction On Obesity Related Morbidity (EAES: Linz, Austria, 1999) 25.

(18.) J B Dixon, M E Dixon, P E O'Brien, "Quality of life after lapband placement: Influence of time, weight loss, and comorbidities," Obesity Research 9 (November 2001) 713-721; M L Schok et al, "Physical, social and psychological quality of life after laparoscopic adjustable gastric banding (LAGB)," Obesity Surgery 10 (April 2000) 110; R Horchner, W Tuinebreijer, "Improvement of physical functioning of morbidly obese patients who have undergone a Lap-Band operation: One-year study," Obesity Surgery 9 (August 1999) 399-402.

(19.) A R Ashy, A A Merdad, "A prospective study comparing vertical banded gastroplasty versus laparoscopic adjustable gastric banding in the treatment of morbid and super-obesity," International Surgery 83 (April-June 1998) 1-3.

(20.) F Favretti, "Laparoscopic adjustable silicone gastric banding (Lap-Band[R]): How to avoid complications," Obesity Surgery 7 (August 1997) 352-358; P E O'Brien, "Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity," British Journal of Surgery 86 (January 1999) 113-118.

(21.) O'Brien, "Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity," 113-118.

(22.) P H Belva, "Laparoscopic LAP-BAND gastroplasty: European results," Obesity Surgery 8 (August 1998) 364.

(23.) F Furbetta, G Gambinotti, "New positioning of the port system," Obesity Surgery 11 (August 2001) 430.

(24.) Dargent, "Laparoscopic adjustable gastric banding: Lessons from the first 500 patients in a single institution," 446-452; E Chelala, "Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases," Surgical Endoscopy 11 (March 1997)268-271.

(25.) M Belachew, "Laparoscopic adjustable gastric banding," World Journal of Surgery 22 (September 1998) 955-963.

(26.) O'Brien, "Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity," 113-118; R Alvarez-Cordero, "Laparoscopic gastric banding: Initial two year experience," 360.

(27.) O'Brien, "Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity," 113-118.

(28.) SAGES guidelines for laparoscopic and conventional surgical treatment of morbid obesity. Society of American Gastrointestinal Endoscopic Surgeons, http://www.sages.org/sg_pub30.html (accessed 7 March 2003).

(29.) "Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--Executive summary: Evidence-based guidelines."

(30.) R C Ramanathan et al, "Equipment and instrumentation for laparoscopic bariatric surgery" in UPDATE: Surgery for the Morbidly Obese Patient, ed M Deitel, G S Cowan Jr (Toronto: FD-Communications, Inc, 2000) 277-290.

(31.) P C Verselewel de Witt Hamer, W E Tuinebreijer, "Preoperative weight gain in bariatric surgery," Obesity Surgery 8 (August 1998) 300-301.

(32.) I Kawamura et al, "A clinical study of protein-sparing modified fast (PSMF) administered preoperatively to morbidly obese patients: Comparison of PSMF with natural food products to originally prepared PSMF," Obesity Surgery 2 (February 1992) 33-40.

(33.) L Lissner, A K Lindroos, L Sjostrom, "Swedish obese subjects (SOS): An obesity intervention study with a nutritional perspective," European Journal of Clinical Nutrition 52 (May 1998) 316-322.

(34.) A K Lindroos, L Lissner, L Sjostrom, "Weight change in relation to intake of sugar and sweet foods before and after weight reducing gastric surgery," International Journal of Obesity and Related Metabolic Disorders 20 (July 1996) 634-643.

(35.) L Busetto et al, "Outcome predictors in morbidly obese recipients of an adjustable gastric band," Obesity Surgery 12 (February 2002) 83-92.

(36.) T E Weaver, "Outcome measurement in sleep medicine practice and research. Part 1: Assessment of symptoms, subjective and objective daytime sleepiness, health-related quality of life and functional status," Sleep Medicine Reviews 5 (April 2001) 103-128.

(37.) Ramanathan et al, "Equipment and instrumentation for laparoscopic bariatric surgery," 277-290.

(38.) G Dominguez-Cherit et al, "Anesthesia during surgery for the morbidly obese patient," in UPDATE: Surgery for the Morbidly Obese Patient, ed M Deitel, GSM Cowan Jr, (Toronto: FD-Communications, Inc, 2000) 277-290.

(39.) "Obesity solutions--International patients, BioEnterics[R] LAP-BAND[R] System--Patient Information, Inamed Health, http://www.inamed.com/products/obesity /international/patient/lapband/information.html (accessed 7 March 2003).

(40.) Ibid.

(41.) F Pasanisi et al, "Benefits of sustained moderate weight loss in obesity," Nutritional, Metabolic, and Cardiovascular Disease 11 (December 2001) 401-406.

Dorothy Roedel Ferraro, RN MS, CS, ANP, CNOR, RNFA, is a clinical assistant professor at State University of New York, Stony Brook, and the director of the Long Island Bariatric Center, North Massapequa, NY.

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