Laparoscopic Adjustable Gastric Band Management

Preoperative psychopathology identified by mental health professionals may predict postoperative psychopathology. Mental health professionals should address pre- and postoperative psychosocial issues (e.g., disordered eating, substance abuse, suicide, depression, lack of social support, and body image/excess skin). Proper LAGB device management, nutrition, and mental health counseling may decrease or eliminate maladaptive eating behaviors. Patients with behavior-related symptoms or diagnoses should undergo postoperative therapy with counseling and appropriate medication, in combination with support groups. Support group attendance should be encouraged for postoperative behavioral and emotional changes.

Clinical nutrition assessments and evaluations should be conducted by an RD for routine follow-up care and in situations where individuals are experiencing dietary complications, excessive or insufficient weight loss, and weight recurrence. RDs should evaluate diet quality and adequacy when symptoms of vomiting, regurgitation, reflux, dysphagia, or food intolerances delay diet progression. RDs should monitor micronutrient status, macronutrient composition, energy requirements, food choices, fiber content, food textures and intolerances related to diet progression and weight change. Prescribing multivitamin and mineral supplements in powder, liquid, or chewable formulations may prevent pill esophagitis. Patients with persistent vomiting should be evaluated for thiamine deficiency and electrolyte replacement.

The most common complications of LAGBs are band slip/prolapse, GERD, esophageal dilatation, band erosion, device, and leak. Treatment options for LAGB complications may include conservative treatment (i.e., medication for GERD, band loosening, nutrition counseling, and behavioral therapy) or band removal. Weight recurrence or insufficient weight loss after LAGB can be caused by dietary, behavioral, medication, and device-related mechanical problems. Device-related complications of LAGB (i.e., device leak, band erosion, disconnected tubing, and port infections) require replacement of LAGB components or band removal. LAGBs can be removed and converted to either sleeve gastrectomy or Roux-en-Y gastric bypass in 1 or 2 stages.

Metabolic and bariatric surgery providers should evaluate patient medications that may lead to weight gain (i.e., mood-stabilizing medications, antidepressants, antipsychotic medications, seizure medications, steroids, antihistamines, beta-blockers, and diabetic medications). Alternative medications that are weight neutral or enhance weight loss and are equally efficacious in treating the medical and psychiatric problem should be considered (i.e., bupropion for depression and glucagon-like peptide -1 agonists for diabetes). A complete medication review should be part of every patient encounter. Adjunct pharmacotherapy may be considered for treating weight recurrence after LAGB surgery. Prescribing antiobesity medications when a patient’s weight plateaus as opposed to after weight recurrence has been shown to prevent further weight gain.

Pediatric population: LAGB surgery is not approved for use in the pediatric population by the Food and Drug Administration despite evidence in several investigational studies showing safety and efficacy after LAGB surgery in young patients. Potential advantages of LAGB treatment for pediatric patients with obesity involve band adjustability, low anatomic complication rates, preservation of the gastrointestinal track, improved overall health status, and the option of band removal, if indicated.

Pregnancy: A tailored approach to LAGB management during pregnancy allows patients and providers to monitor weight gain, nutritional adequacy, and fetal growth for a healthy pregnancy outcome. Evidence supports LAGB placement as safe and well tolerated during pregnancy with close LAGB monitoring. One risk that should be discussed with patients prior to conception, during pregnancy, and postpartum is band slippage.

Experienced providers (i.e., surgeons, primary care, RDs, mental health professionals, nurse practitioners, nurses, and physician assistants) should be part of the multidisciplinary team in LAGB management. Providers should have training and experience with the specific LAGB fluid volumes, adjustment schedules or algorithms, and potential complications. Management of LAGBs requires provider competency in understanding physiologic mechanisms (i.e., vagus nerve, hormones, and gut motility) affected by LAGB placement and fluid volume adjustments. Fluid removal and a referral to a metabolic and bariatric surgery provider should take place when a patient experiences significant dysphagia, vomiting, regurgitation, reflux, or symptoms of heartburn. Fluid removal and referrals for nutrition and behavioral health counseling should be considered when patients experience maladaptive eating behaviors, feelings of uneasiness with eating, or an inability to tolerate solid-food textures. Additional fluid may be considered when a patient tolerates large portions of solid foods, feels a lack of satiety, or senses that hunger and appetite are not well controlled. Providers may consider regularly scheduled
diagnostic evaluation (i.e., upper gastrointestinal radiologic study) of patients with long-term LAGB management.