Postoperative outpatient treatment, post treatment

Upon being discharged the patient will receive an implant ID card. This will show general information about the implanted band and note information about the treating surgeon and his/her availability. The patient must carry this ID card with him/her at all times, as it will inform physicians treating emergencies concerning the patient’s "Stomach band operation" status. Also, physicians performing operations that are not directly related to the patient’s adiposity (e.g. orthopaedic measures) need to be informed of the stomach band. Before administration of any general anaesthetic, the stomach band must be opened completely. This can only be done, using a special needle, by physicians with experience in this field.

The patient must be educated about possible symptoms in the event of complications. In case of problems ingesting foods, the patient should immediately consult with the surgeon and in the event of complete inability to ingest fluids should report to the clinic’s emergency unit. Small rural hospitals not experienced in bariatric surgery should be avoided if possible. Travel to foreign countries or vacations abroad should be postponed; this topic must be discussed with the surgeon responsible before the surgery and before leaving. The patient must be willing to commit to lifelong check-ups with the physician, and should not leave the clinic before an initial outpatient appointment is scheduled. From experience, 3 -4 weeks has proven to be a favourable timeframe.

The patient’s understanding of the timeline for the obesity-therapy is critical for continued progress. Preparations, surgery and a stay at the clinic only make up a small, albeit important, part of the treatment. The intentionally long phase of weight reduction (usually stretching over 18 months) and the lifelong maintenance of the goal weight are only starting at this point (fig. 13). The desired weight ranges from 50 – 60% excessive weight loss (EWL). For example: the desired weight-loss for a female patient 1.6m tall and weighing130kg is 40kg over a period of 2 years. During this period the weight curve will not always progress in a linear manner (i.e. the same loss of weight over the same periods of time), but may stagnate, especially in periods shortly before band readjustments.

: Fig. 13: Timeline for treatment of morbidly obese patients

Overall, 5 readjustments of the band will be necessary before the desired fill volume is reached. Excessively rapid weight-loss or excessively quick restriction of the stomach carries with it substantial risks (pouch complications, deficiencies, gallstones) and should be avoided. If weight remains the same as therapy progresses, it is better if the physician and patient maintain a sense of calm as the reasons are usually recognised quickly and corrected accordingly: readjustment of the band, omission of hidden calories (e.g. in liquid form). For the patient’s psychological well-being, it is important to avoid weight-gain or excessively severe fluctuations.

Until osseointegration of the stomach band is complete, meaning for 6 weeks after the surgery, the patient must not ingest any solid foods, thus avoiding disturbances of the osseointegration-process through overly straining the pouch while the band is being enveloped in a connective tissue sheath. The stomach band is not be constricted until the patient has switched to solid foods, which takes about another 1 – 2 weeks, thus it remains open up to this point in time (7th to 8th week). It is of utmost importance that the patient take enough time for meals during this phase of switching. The patient should learn to eat slowly (about 45 min. per meal) while the band is still open, and to not drink during meals under any circumstances. This is absolutely necessary for the band to function properly later on.
Repeated vomiting should be avoided. If it occurs, however, the reasons are either severe malnutrition implying that recommendations were ignored, other diseases like stomach/bowel infections (gastritis) usually causing other symptoms, or pouch complications (see also Postoperative Complications).
Thirst should be quenched by drinking up until shortly before eating. A long pause before the meal is not necessary, since a stomach band, even at maximum constriction, should not hinder the passage of fluids. While eating and for 2 hours afterwards, drinking must be avoided. Only then will the stomach band function in the desired manner. Only well chewed foods – and items small enough so as not to clog the stomach band – will pass to the pouch as a relatively viscous mush, remain there in small amounts due to the pouches reduced volume, and then be passed through the pouch exit to the main stomach. A filled pouch will signal satiation even when the pouch is no longer full. Premature drinking would either reduce this effect by diluting the food mush and washing it through the pouch exit, or the pouch would inflate rapidly causing the patient to vomit the pouch contents, which may cause complications (pouch dilatation) if it occurs repeatedly.

Regarding food preparation and selecting a balanced diet with all the necessary components, the patient will be given nutritional counselling and suitable printed guides before being discharged. The diet should be low in fat and rich in vitamins and proteins. Carbohydrates will serve as an energy source. In addition, special attention should be paid to the calcium and iron supply. If in doubt, a nutritional counsellor familiar with stomach band insertions is available at any time.
Until the desired target weight is achieved, after approx. 2 years of following a balanced diet of solid foods, patients should take a multivitamin preparation daily, preferably in the form of a dissolvable tablet or powder. This preparation should only contain water-soluble vitamins (e.g. B-complex, C), which do not accumulate in the body, since they can be evacuated through the kidneys without any problems. Preparations containing fat-soluble vitamins (A,D,E,K) should be taken only sporadically or under the supervision of a physician because overdosing symptoms may occur.
To provide the utmost patient satisfaction, and thus optimum results, lifelong aftercare is necessary for patients. Complications, deficiencies and erroneous developments should be detected at an early stage. Aside from periodic clinical check-ups, lab examinations, endoscopic and radiological check-ups are also necessary (see table 20 for more information).

Month

Consultation

(x)

Adjustment

(x)

Lab

(x)

X-ray

Gastroscopy

(x)

Nutritional
counselling

x**

Photo
documentation

Body
composition***

*	In the 2nd year after surgery check-ups in 2 – 4 month intervals as required
**	After the first two consultations as required
***	Impedance measuring: Basal metabolic rate, fat, cell mass, water content

Tab.20: Clinical check-ups and examinations for gastric banding

Postoperative outpatient treatment, post treatment

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