Postoperative management and nutritional assessment of laparoscopic vertical gastric banding

Postoperative management and nutritional assessment

The patient was admitted to the hospital on the morning of the surgery and stayed for a total of 23 hours. Low molecular weight heparin and prophylactic antibiotics were given before the surgery.

Postoperative intravenous fluid replacement is administered. If tolerated, a clear liquid diet is given on the evening of the operation, and intravenous or oral analgesics are used to control wound pain.

Avoid using nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, and aspirin, as there are risks of postoperative bleeding at the incision site, ulceration, or bandage corrosion. These complications can occur due to prolonged contact between the drugs and the gastric mucosa caused by drug retention in the gastric pouch.

Patients with severe arthritis or joint pain who require nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors can take them after 6 weeks of oral proton pump inhibitors. However, the risk of bandage corrosion and gastric cyst ulceration is still increased when taking these drugs.

Preoperative preparation with elastic stockings can reduce the risk of deep vein thrombosis.

If the patient is clinically stable and can tolerate fluid and oral analgesics, they can be discharged on the morning of the second day after surgery.

Because an endoscopy was performed during the surgery, routine meglumine diatrizoate contrast imaging was not required.

However, if there are symptoms of leakage or obstruction, such as fever exceeding 101 degrees Fahrenheit (approximately 38.3°C), sustained tachycardia exceeding 120 beats/min, nausea and inability to eat, we will perform diatrizoate meglumine contrast radiography.

Postoperative follow-up examinations are required at 3 weeks, 3 months, 6 months, and 1 year, and then once a year thereafter.

Laboratory assessments and nutritional monitoring were conducted at 6 and 12 months post-surgery, and annually thereafter.

Monitor complete blood cell counts, biochemistry, serum iron, and vitamin B₁₂ levels.

Even after VBG, nutritional monitoring is still necessary because the diet may not provide enough healthy nutrition.

Patients are required to fill out a 2-day diet log during follow-up visits starting 3 months after surgery.

We have observed that carbohydrates make up approximately 85% of the diets of many patients.

These patients need to increase their intake of protein and fiber in their diet.

Based on our experience, the main reasons for weight loss failure after laparoscopic VBG are poor eating habits (eating small amounts of high-calorie "junk" food throughout the day to avoid vomiting, eating sweets or high-calorie carbohydrates) and not exercising.

Complications and controversies of laparoscopic vertical gastric banding

Laparoscopic VBG has all the complications of traditional open surgery, as well as complications unique to minimally invasive surgery, such as limited movement of surgical instruments, inaccurate positioning of surgical procedures, and lack of feel for the instruments.

We will only discuss how to avoid complications and technical points of contention in laparoscopic surgery.

Patient selection is a major factor, especially for doctors who are new to this procedure, because not every patient is a suitable candidate.

Female patients with a BMI of less than 50 and no history of open abdominal surgery were selected to reduce the chance of conversion to open abdominal surgery.

After performing at least 100 of these surgeries, the restrictions on weight and previous surgical history can be relaxed.

The reason for converting to open surgery is often due to the large liver obstructing the surgical field and the instruments being too short to reach the upper part of the stomach for dissection and treatment.

In our case, 1 case (1.7%) was converted to open surgery, while Olbers et al. reported 6 cases (4%) converted to open surgery due to a large left lobe of the liver.

This risk can be reduced by adopting a low-carbohydrate, high-protein diet for 10 days before surgery to decrease liver volume.

In addition, we do not encourage patients with a BMI over 50, a sweet tooth, diabetes, or high cholesterol to undergo any restrictive surgery, as gastric bypass surgery has better efficacy.

When conversion to open surgery is necessary due to short surgical instruments, the likelihood of conversion can be reduced by selecting patients weighing less than 400 pounds or with a BMI of less than 60, using 45cm long instruments, and employing new ultra-long cutting and closing devices.

In addition, inserting the cutting and closing device directly through the abdominal wall without using a trocar can increase the length of the cutting and closing device by an additional 2 cm.