Evaluation of the Pregnancy and Birth Outcomes after Gastric Banding Surgery

Prevalence of the obesity that has been increased at recent years present the gynaecologists with obese pregnant women’s problems. At the women’s pregnancy period, obesity causes to increasing of some risks both for the mother and the baby will new born. The most important birth problems for the mother are premature birth risk, increased problems at the moment of birth, hypertension induced by pregnancy and preeclampsia, pregnancy diabetes and excess weight gaining during the pregnancy. On the other side intrauterin growth retardation, macrosomia and fetal growth anomalies are more frequently encountered for the baby.

Here, I will try to examine the outcomes of gastric banding (staple) surgery which we have encountered as a frequently used method at obesity treatment, on pregnant obese women.

Bar-Zohar et al. (Pregnancy after laparoscopic adjustable gastric banding: perinatal outcome is favorable also for women with relatively high gastational weight gain. Surg Endosc. 2006;20:1580-3) have evaluated 74 women those have become pregnant after gastric banding surgery and defined mean gained weight as 10.6±2.1 kg in their study. All births have realized after the 39_th week and mean birth weight has been identified as 3.09±0.5 kg. Major congenital anomaly at women, post-natal hypoglycemia at babies, baby death during or after the birth have not seen. In the light of these findings the authors those have performed this study, have been stated that; pregnancy and birth after gastric banding surgery are considerable confidential both for the mother and the baby.

John D. Dixon et al. (Birth outcomes in obese women after laparoscopic adjustable gastric banding. Obstet Gynecol 2005;106:965-72) have indicated that pregnancy and birth outcomes of the women those have underwent gastric banding surgery are in compliance with values of the women those have become pregant with normal weight and as a result they have pointed out the reliability of this method on pregnant obese women. Adjustability of the staple is an important feature, because this provides the ability for adaptation of the surgery procedure as per pregnancy requirements. A multidisciplinary approach included collective collaboration of obesity surgeon and gynaecologist has been suggested after such applications.

Vejux N et al. (Pregnancy after gastric banding: maternal tolerance, obstetrical and neonatal outcomes. Gynecol Obstet Fertil 2007;35:1143-7) have made evaluation by studying on 7 papers concerning this issue. With regard to obtained data they have ben stated that gastric banding surgery is quite tolerated during the pregnancy and it could be suggested to the obese women in the age of birth child.

The studies mentioned above have showed the pregnancy problems depends on obesity may result in quite high danger. The weight loss after gastric banding which has been commonly used at recent years decrease these risks. The women those have underwent gastric banding operation and then become pregnant can complete their pregnancy process in a successful way without removed their staples and in company with the regular controls.

Assoc. Prof. Halil Coskun M.D.

Evaluation of the Long Term Results of Gastric Banding Surgery

One of the most preferred method (Europe, Australia and USA) at obesity surgery for today is Laparoscopic Gastric Banding Operation. Approximately over 500.000 patients have been estimated to receive the application in the wolrd up to the present. Long term result of this operation are presented in details following.

Favretti et al. (Laparoscopic adjustable gastric banding in 1,791 consecutive obese patients: 12-year results. Favretti F, Segato G, Ashton D et al. Obes Surg. 2007) have implemented laparoscopic gastric banding operation to 1791 patients between 1993 and 2005. 75.1% of patients were female and 24.9 % were male, mean age was 38.7±10.9 years, mean weight was 127.7±24.3 kg and mean BMI has been identified as 46.2+7.7 kg/m². 91% of the patiens have been followed up for a period of 12 years. At first, BioEnterics Intragastric Balloon (Stomach Balloon) has been implemented to 125 of the patients and after providing them to loss weight in a certain extent, Gastric Banding has been implemented. Major complication rate due to operation was 0.05 – 5.9% and minor complication rate was 0.5 – 11.2%. Mortality due to operation (death) has not been developed at any patient. At following up for 10 years weight loss was 101.4+27.1 kg (mean 26.3 kg), BMI loss was 37.7+9.1 kg/m2 (mean 8.5 kg/m2) and excess weight loss percentage was 38.5+27.9%. Regression and treatment have been defined at 36.2% of the patients with Type 2 diabetes and 60.6% of the patients with hypertendsion. At the statistical analysis that has been executed in this study on life expentancy longer-term life has been identified at the patients with the gastric banding than those have not gastric banding.

Mittermair et al. (Results and Complications after Swedish Adjustable Gastric Banding-10 Years Experience. Mittermair RP, Obermüller S, Perathoner A et al. Obes Surg. 2009) have the opportunity at their assessment to follow-up 785 patients those have been underwent Laparoscopic Gastric Banding for a 10 years period. The patients have showed mean loss of 26 kg at first year whereas this weight loss has been mean 40.5 kg at the last of 8 years. Excess weight loss percentage has been defined as 65.5%. Mortality due to operation has not been developed at any patient.

In a conclusion, Laparoscopic Gastric Banding is a method easy to implementation with short length of stay at hospital and which has provided permanent weight loss in a long term. Patient compliance is extremely important at this applcation and the band doesn’t required to be removed if there is no any problem developed.

	Patient Number	Follow – Up	Excess Weight Loss Percentage
Favretti et al.	1791	12 years	%38.5±27.9
Zehetner J et al.	190	6 years	%50
Toouli J et al.	481	5 years	%49.8
Miller K et al.	158	4 years	%54.7
Zinzindohoue F et al.	500	3 yıl	%54.8

Assoc. Prof. Halil Coskun M.D.

Nutrition Plan after the Gastric Banding Application

Adjustable Silicon Gastric Banding Surgery forms the first step of the change has been realized at the patient’s life style. The time of recovery will be advised you to maintenance yourlife more comfortable, to complete the healing due to operation you have underwent and to comply with the new stage of your life.

The patients have to learn the importance of chewing at the foods they have taken. They should also understand the importance of physical exercises and that they should bring those exercises as a part of their life. It is important to eat with the a baby spoon and to swallow as very small pieces at the beginning as you are new to the gastric band. Food intake with large pieces, may cause to pain and vomitting by making obstruction at the passage where the band is. You have to make a long time for yourself for eating. This duration must include a time period of 45-60 minutes. If you eat fast and much, this will lead to problems. The pouch above the band is very small and if you eat much the foods immediately come back. As you learn with time to eat slowly, you will better fill the band and understand when you have eaten enough and you will learn when will you end the eating without vomitting.

The patient’s diet should include only liquid foods at the first month after the surgery. Because the body needs time to heal and to provide adhesions those will fix the band at accurate position. At the patients those have hurried for solid foods intake, prolapsing of the band and expanding of the upper stomach pouch by this way are inevitable.

Liquid intake begins at the first night after the operation. A spoonful water is given at each 5-10 minutes until 250 ml (a glass of water) has been completed. Rest of the fluid need will be given by serum. Oral liquid intake is rapidly increased at following days. All fluid need at the diyet is begins to be met at 3rd day without the need to serum.

Liquid and solid food need after the patient has been discharged should be met as follows :

First 4 weeks

Liquid diet during first 4 weeks. On average 100 ml liquid is taken in small amounts with tablespoon each hour. Type of the liquid must differ and low-fat milk, yoghurt, gruel, tea, fruit or vegetable juice, warm soup or broth should be preferred. Diet supporting drinks must be added to provide balanced nutrition. It is important to spread the liquid intake to all of the day with small amounts. This period of time is very important for your stomach to heal. Fast beginning to the solid foods may damage your stomach and the band.

4 – 6 weeks

Pureed diet during 4 – 6 weeks. The puree should be taken in small amounts. Soup and nutritional supports are still added to the diet. A lot of markets sell baby food suitable to 5-6 months babies. These formulas are very useful at this period because they have included proper food ingredients.

The patients should drink water between the meals, not with the meals. The meal times can be adjusted according to the patient’s condition but recommended amounts should be checked as possible. Total liquid intake must be at least 1500 ml daily. The liquid should be taken at regular intervals and 100-200 ml at each time. Type of the liquid should be alternated and tea, milk or yoghurt, fruit – vegetable juice should be tried. Pureed food intake must be kept at 500 gr daily.The purees should include meat or fish meat and should not exceed 100-150 gr at once. The food should be eaten in small amounts and slowly everytime.

6 – 8 weeks

Normal foods in small amounts during 6 – 8 weeks. Foods with normal ingredients can be include to the diet. But they should paid attention to be in small amounts and to be taken between the meals. It is very important to eat slowly and to chew completely.The patient can take low fat milk or yoghurt.

Total liquid intake must be at least 1500 ml and the solid food intake must be kept around 500 gr. Solid foods now can be taken at normal mealtimes. However it is very important to eat slowly.

8th week and later

The patients now define their own food menu. Frequently, but slowly eating and completely chewing are still important. The liquids can be drunk only between the meals and as sugar free. The diet must mainly include boiled or crushed vegetables. Fish or low fat meat should be boiled rather than fried. Other foods also must be with low fat (milk and light cheese that have 17% fat in maximum).

FOOD LIMITATIONS

Some foods can not be easily tolerated and they should excluded from the diet unless they have converted to the alternative products those have been digested better. These are the foods which have generally got stuck on the cardia and caused to vomitting and lacking of liquid as a result of blokage.

Altough most of the patients can tolerate when they have chewed well the meats like steak they have difficulty to digest thick piece of the meat. Therefore it is recommended to avoid from eating meat and to gradually involve the meat into diet. Each patient has got his/her own eating capacity. Don’t compare yourself with the other patients eating.

LIMITED FOODS

Solid Foods

White, crusted thick bread

Dry meat, steak (boiled meat should be preferred instead of steak but it must chewed very well and digested in small pieces – after 8 weeks)

Fried potatoes

Cucumber, corn

Orange (It’s fibres may create problems when it has been digested – ATTENTION)

Fibrous Foods

Asparagus, it can be mixed in soup

Pineapple, it can be crushed for juice

Broccoli, it can be used only for it’s branches

Citrus fruits and dried fruits should be definitely avoided since they have obstructed the cardia by swelling.

Fatty Foods

Coconut

Potato chips

Popcorn

Soft white bread

Difficult to Digest Foods

Hazelnut

Almond

Peanut

Soda (carbonated drinks may make feel discomfort)

This list contains the foods which patients have experienced problems. Problem, doesn’t mean ‘imposible’. But it really required you to chew very well and eat slowly. Even so, it will be appropriate for you to make your choice in favor of the other foods.

You may harm your weight loss by taking high calorie foods (like chocolate, desert, ice cream and alcohol). Don’t wait from the band to do everything, know that the power is in you.

If you encounter a problem post operation, don’t hesitate to call your doctor and make your checks done regularly.

GOLDEN RULES

1 – You definitely must eat very very slowly. Comply with this rule even your eating a small portion takes your 45 minutes.

2 – You must chew very well.

3 – Carbonated drinks (soda, fizzy drink, cola) and effervescent drugs (Tylol Hot, Calcium Sandoz etc) are definitely forbidden. Gas bubbles in the liquids may expand the small pouch of your stomach.

4 – You must drink water between the meals. Otherwise quantity of the water that you have drunk with the meals is added to the food’s volume and it may be too much for your small pouch.

5 – You must divide the foods into small pieces before you take them to your mouth.

6 – You must chew the bite very well and swallow slowly after you have taken it to your mouth. Don’t forget to make your teeth checked to define whether your chewing is enouh or not.

7 – You must stop the eating when you have received the first signals of fullness. Even a more spoon may be too much and you may vomit (or you may feel pain at the area where the band is, your stomach pouch may expand and this can cause to form a second pouch and worthless of the band.

8 – You should joint to different exercises (swimming, gym, walking, dancing etc.) according your ability and preferences twice a week.

Assoc. Prof. Halil COSKUN M.D.

Laparoscopic Gastric Banding Surgery

Gastric Banding Surgery has been brought forward with it’s first time application by Dr. Kuzmak, an American surgeon. The essential of the application is to insert a silicon band to upper part of the stomach just below the esophagus as to form a volume of approximately 15-20 cc. In simpler words is to bring the stomach into sandglass shape.

This is a restrictive (that limits the stomach volume) operation. The essential of weight loss is based on the limited food intake by decreasing the stomach volume. It is not possible to intake excess food when the small stomach which has been formed as a result of staple insertion got full.

The most important feature of the staple is inflatable effect by giving fluid to its internal reservoir. Thus, the openness that has provided the connection between the upper small stomach and lower stomach parts can easily be adjusted. The advantage is that if the person’s eating is much the food intake can be decreased by this adjustment and weight loss can be increased in this way.

This adjustment is made through a connection tube with reservoir at the end. This reservoir is inserted on the muscle layer under the skin. By this way the transition from upper stomach to lower stomach can be limited by inflation of internal volume of the band through fluid has given by an injector.

The most important thing which should be paid attention at the patients those have considered the gastric banding is to examine their eating habits. Particularly the persons called ‘sweet eaters’ who have nutrition habit with the high calorie foods (ice cream, chocolate, dessert etc) must be careful. Because these types of foods are small in the volume and high in the calorie. Hence, no matter how much the staple is adjusted at the patients with stomach stapling, weight loss rates will decrease as intake and passage of these foods will be easy. Many specialist suggest gastric bypass for long term weight loss at morbid obese persons (BMI>40 kg/m²) and the sweet eaters.

Most important advantage of this operation is to be executed laparoscopically and the short length of stay at hospital (1 – 2 days). Returning to work is faster and quicker. But the patients need some time to shift to the solid foods after operation. It is no longer imposible to maintain an eating habit as before. Compliance with the rules is very important for this operation, otherwise some problems can be encountered with the staple and this can lower the weight loss rate.

Most important problems those can be experienced after the stapling can be specified as; reaction of the body against the staple (rarely), sliping of the staple from the place where it has been inserted in the stomach or changing of it’s position, going forward into the stomach (rarely) and infection at the reservoir. Sometimes a secondary operation is required at such cases as well as the removal of staple. Incidence of the complications have been mentioned differs at a range of 1 – 10%.

Weight loss at the long term differs at a range of 50 – 60% of the excess weight at the monitoring after stomach stapling. (at 7 – 10 years monitoring)

In conclusion the stomach stapling application is an operation which has satisfactory level of weight loss rate at long term and can be easily implemented to the morbidly obese patients those have been called as ‘non-sweet eaters’ and haven’t got a habit of nutrition with high calorie foods.

Assoc. Prof. Halil Coskun M.D.

halilcoskun@hotmail.com

Intragastric Balloon Application (Endoscopic Video)

BioEnterics Intragastric Balloon

Heliosphere Intragastric Balloon

Intragastric Balloon Application Sedation Anesthesia

Intragastric balloon application is an effective treatment option which has gained popularity in recent years. The patient must be comfortable and compatible for this operation can be executed. Generally there is high anxiety (excited and nervous) level at these patients since they are in a nervous mental state because of thinking and worrying about how will conclude the operation and whether they will feel the attempt during the operation or not. A kind of sleep state that we have called “sedation” is an ideal anesthesia method for this attempt. The quality of sedation anesthesia during that short lasting attempt simplifies the attempt as well as enables it to complete without awareness of the patient. Necessary care is shown to provide the patient has a hunger level for 6 hours pre operation.

An anesthesiologist evaluates the patient before the sedation application. He learns his/her diseases have been experienced and the habits. Anxiety of the patient is important and defining it is guiding the drug doses will be administered.

Vascular access of the patient is opened before the operation. A catheter is placed in the one of veins at the hand or arm. All of the drugs and serums are given through this way later.

Whole operation is executed at the operation room with the secure conditions. After the patient has lied on the stretcher, a relaxant is given from intra venal and the patient began to be followed. The patient is admitted to operation room after enough relaxation (additional drug is given if there isn’t any change for desired level). Additional drugs are given to patient at operation room to provide more sound sleep. The attempt is begin after the providing enoygh sleep level. The patient is in the deep sleep now and he/she doesn’t hear and feel anything almost. When asked to them, the patients have stated that they didn’t remember anything after, our experience of over 450 cases performed by A/P Dr. Halil COSKUN in our application center. Most of them have indicated that they didn’t believe at the first period that the ballooon has been inserted. The mean duration for all of this implementation is 20 – 25 minutes.

The patient is admitted to the rest room in the operation room after the attempt. He/she is kept waiting here and observed and sent to the room when the vigilance level reach to desired level. The patient keeps sleeping if he/she spent the night sleepless and tired, but responses if spoken. Our patients are discharged with suggestions after keeping under observation for 4-6 hours at hospital.

Intragastric balloon removal operation is executed in the same way by implementing of sedation anesthesia. Our patients are discharged after keeping under observation for 2 hours after the removal of the balloon.

Sedation anesthesia is a very ideal and secure method. But it should not be forgotten that this ways to provide sleeping should not be applied without anesthesiologist and full equipped operation room. Because the immediate distribution of sedative drugs differs as to the fat mass index could be high at the obese persons. It should be took care to comply with the rules for providing the highest level safety of the patient.

Assoc. Prof. Halil Coskun

Intragastric Balloon (Technical Specifications, Types and Comparisons)

There are 3 types of patented intragastric balloon in the world for today (September 2009). Two of them are fluid injection intragastric balloon (Bioenterics® ve Silimed®) and one is air injection intragastric balloon (Heliosphere®). The processing mechanisms of each three products are technically similar.Following you can look over to technical comparisons of three products.

Editor’s Comment 1

Although the intragastric balloons have technically similar features, Heliosphere®, has encountered with some problems related with design at the patent stage and it’s implementations are going on in the some centers in Europe and in our country for the present. The key problems related with the product are those the scientific data on Heliosphere® is insufficient and the multicentric results still haven’t been published. In addition it isn’t possible to be noticed by the operator in the event of puncture at the balloon because of Heliosphere® is inflatied with air.
Bioenterics® intragastric balloon is the most implemented product in the wolrd and in Turkey and it’s scientific results have been declared. Particularly in Italy at Europe and in Brasil at South America multicentric study results have been published and it’s efficiency level has been proved.
Similar results have been seen when you look at the weigh loss outcomes. The scientific study results for Heliosphere® those will be published in the coming years will be more useful to show the differences and the similarities between two products.

Editor’s Comment 2 : (October 2009)

In addition to the previously used 2 intragastric balloons, fluid injection Silimed® Intragastric Balloon which has been included to the field of application with the completion of the patent stage in 2008 has been also began to be used. This intragastric balloon is quite similar to Bioenterics® Intragastric Balloon. It is a very important characteristic to be injected with fluid and it is seen at the same value with Bioenterics® in confidence.
Heliosphere Intragastric Balloon has realized a change in design structure in 2008 again and the case structure on the balloon has been changed to prevent the air leakage. Furthermore the capacity of this gastric balloon has been also lowered from 900 cc to 600 cc like the other fluid injection balloons.
Gastric balloon applications are continued to be used as common practice all over the wolrld. Altough they are used to prepare particularly the obese patients with very high weigh (BMI>50kg/m2) to the surgery treatment, they are also suggested to be used as an auxiliary and supporting treatment method to provide weigh loss at the overweight patients those have (BMI 27 – 35 kg/m2) at the beginning of the obesity but couldn’t lost weigh with diet or other treatment methods.

Assoc. Prof. Halil COŞKUN M.D.
www.halilcoskun.com
halilcoskun@hotmail.com