rectus sheath at this site using nonabsorbable sutures with open surgical technique. We close all large port site.
The skin wounds are irrigated, local anesthetic solution injected for postoperative analgesia, and closed. No intraperitoneal drains are left.
Immediate Postoperative Management
Early postoperative ambulating is encouraged. A barium swallow is performed the morning after surgery to confirm correct band positioning and to rule out gastric injury. If this examination is normal, the patient is allowed to begin oral liquids and discharged from the hospital within 24 hours of the procedure. A pureed diet is usually tolerated within a few days of the surgery and is continued for a month. The patient should be cautioned that over-eating, nausea and vomiting might be dangerous.
Band adjustments should begin no less than one month following successful surgical placement. This is done to allow for formation of a pseudo-capsule around the perigastric band to decrease the risk of early postoperative band slippage or gastric herniation. The strategies for band adjustment varies. Narrowing the lumenal diameter of the band by injection of saline requires sterile technique and, sometimes fluoroscopic guidance. Up to a total of 4 ml of saline can be injected into the reservoir for maximal constriction before concerns arise about damage to the band from overinflation. A logical adjustment strategy is to progressively narrow the band diameter until the patient begins a steady and sustained weight loss. One approach is to inject 1/2 ml of saline into the band at intervals of 2-4 weeks between injections while monitoring the patient's intake of both calories and food groups. Patients must be repeatedly told to avoid sugar and other sweets that provide a high caloric intake in a small volume, since sweets-eating behavior is one of the more common reasons for failure of gastric restriction procedures for obesity. We have routinely excluded patients with identifiable sweets-eating behaviors from undergoing gastric restrictive procedures. Despite this, we have seen many patients develop sweets-eating behavior when faced with the postoperative limitations in quantity of oral consumption imposed by the procedure. Repeated dietary counseling may help avoid, and occasionally treat, such oral indiscretions. However, more commonly, patients who act on their cravings for sweets either fail to lose weight or regain their lost weight.
While few surgeons perform routine contrast studies of the gastrointestinal tract before band adjustment, this was mandated in the 'A Trial' in the United States. Band stomal diameter was estimated radiologically before and after band adjustment. A representative contrast study of a well-positioned Lap-Band is seen in Figure 7.4. A contrast study of a patient with acute gastric herniation through the band with obstruction is depicted in Figure 7.5. In our series of 36 Lap-Bands, 18 of 25 patients (71%) who had both preoperative and postoperative contrast studies demonstrated postoperative esophageal diameter an average of182 % (range 100 to 286%) of baseline diameter over an average period of 21 months. Although there are no standard methods in the literature for measuring esophageal dilation by contrast esophagram, we standardized our measurements by using the vertebral body height and band diameter to provide internal controls for variable film magnification. Our review suggests that normal resting esophageal diameter should be less than 16 mm. In our LASGB patients, stoma diameter and amount of weight loss did not correlate with the degree of esophageal dilatation. The mean preoperative esophageal diameter was 2.2 cm (range 1.4 to 3.1 cm), which increased to 3.3 cm (range 1.9 to 4.8 cm) postoperatively. Two patients presented to our clinic from other centers with esophageal dilatation and resulting symptoms. Saline was removed from the reservoir, which only minimally decreased the degree of dilatation. Contrast exams revealed 11 patients had delayed esophageal emptying, five had decreased motility, and seven had both. Bands were removed in two patients due to symptoms related to esophageal dilatation. Twelve of 17 patients with severe dilatation were symptomatic with dysphagia, vomiting or severe reflux. Five of six patients with the greatest postoperative esophageal dilatation (> 200% of baseline diameter) were symptomatic. Two patients had pouch dilatation. Of the seven patients in our series who were not significantly dilated on contrast studies, six had only short-term follow-up, suggesting that dilatation may not develop until beyond one year postoperatively.
We tightened the band despite the presence of varying degrees of esophageal dilatation on the pre-adjustment contrast esophagram in eight patients. This occurred before we recognized the high incidence of esophageal dilatation in our LASGB patients and altered our adjustment strategy. Fluid was not removed from the band in several patients because of inadequate weight loss. Worsening esophageal dilatation and inadequate weight loss mandates conversion to proximal gastric bypass.
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