Gastric Restrictive Surgery

What is gastric restrictive surgery?

Gastric restrictive surgery is a type of bariatric surgery or weight loss surgery. It limits the amount of food you can eat. This surgery may be used to treat severe obesity when diet, exercise, and medicine have failed.

The normal digestive process stays intact in gastric restrictive procedures. None of the gastrointestinal tract is bypassed. There are two types of operations:

• One separates the stomach into two parts. One is a very small pouch that can hold only about 1 ounce.

• The second type removes about 80% of the stomach. The remaining stomach is much smaller.

These procedures are called “restrictive” because the size of the stomach is reduced so much.

You can only eat about three-quarters to a cup of well-chewed food after having a restrictive procedure. Eating more than the stomach pouch can hold may cause nausea and vomiting.

Restrictive procedures have fewer risks than gastric bypass procedures. But they may be less successful. That’s because continuous overeating can stretch the pouch so that it holds more food.

The types of gastric restrictive procedures are:

• Laparoscopic adjustable gastric banding (LAGB). In this method, your healthcare provider attaches an inflatable band around the top part of your stomach. The band is tightened like a belt. This separates the stomach into a small pouch. This pouch serves as a new, much smaller stomach. The rest of the stomach is below the band. The band creates a narrow channel between these two parts of the stomach. This slows the movement of the food from the upper small pouch to the lower stomach. The band can be adjusted as needed by your healthcare provider after the procedure. This is done by adding or removing saline (salt water) to an attached port. This is underneath the skin. No staples are used. This is because no part of the stomach is usually removed. Like other restrictive procedures, LAGB may not help you reach significant weight loss. 

• Vertical sleeve gastrectomy. This newer procedure uses staples to remove about 80% of the stomach. The remaining stomach is shaped like a "sleeve." It will hold about one-quarter cup of liquid. Over time, the stomach can expand to hold 1 cup of food. You can potentially lose 1/3 to 1/2 of your excess body weight at one year after surgery. This procedure is not reversible since the rest of the stomach has been removed.

LAGB is most often done using a laparoscope rather than through an open cut (incision). This method uses a few small incisions for the laparoscopic tools to reach the inside of the stomach. The surgeon does the surgery while looking at a TV monitor. Laparoscopic gastric surgery usually reduces how long you'll need to stay in the hospital. It also reduces the amount of scarring, lowers the amount of pain after surgery, and often results in quicker recovery than an "open" or standard method.

Why might I need gastric restrictive surgery?

Bariatric surgery is currently the best choice for lasting weight loss in people who are severely obese when nonsurgical methods of weight loss have not worked.

Potential candidates for bariatric surgery include:

• People with a body mass index (BMI) greater than 40

• People who have a BMI of 35 or more who have another serious weight-related condition, such as type 2 diabetes, sleep apnea, heart disease, high blood pressure, or osteoarthritis

Because the surgery can have serious side effects, the long-term health benefits must be greater than the risks.

People with a BMI of 60 or more or those who have already had some type of stomach surgery may not be able to have laparoscopic surgery.

Although not all risks are fully known, bariatric surgery does help many people reduce or get rid of some obesity-related health problems. It may help to:

• Lower blood sugar

• Lower blood pressure

• Reduce or eliminate sleep apnea

• Decrease the workload of the heart

• Lower cholesterol levels

• Reduce the chances of osteoarthritis of lower back, hips, and knees getting worse

Surgery for weight loss is not for everybody. But these procedures can be highly effective in people who are motivated to follow their healthcare provider's guidelines for nutrition and exercise after surgery.

There may be other reasons for your healthcare provider to advise a restrictive gastric procedure.

What are the risks of gastric restrictive surgery?

As with any surgery, complications may happen. They may include:

• Infection

• Blood clots

• Pneumonia

• Bleeding ulcer

• Gallstones

• Obstruction or nausea when food is not well-chewed

• Poor eating habits

• Nutritional deficiencies

• Scarring and adhesions in the belly (abdomen). These can lead to bowel blockage.

• Vomiting because of eating more than the stomach pouch can hold, not chewing food well enough, or eating food too fast

• Heart attack or heart rhythm problems (arrhythmias)

• Stroke

• Death

In LAGB, the band can erode into the stomach or slip. This can block the flow of food through the band. Rarely, stomach juices may leak into the stomach and emergency surgery may be needed. A common long-term complication with LAGB is that the stomach pouch enlarges.

Laparoscopic banding procedure has fewer risks because there is no incision made into the stomach wall.

There may be other risks based on your specific health condition. Be sure to discuss any concerns with your healthcare provider before the procedure.

How do I get ready for gastric restrictive surgery?

• Your healthcare provider will explain the procedure to you and ask if you have any questions.

• You will be asked to sign a consent form that shows that you understand the operation and its risks. It also gives your healthcare provider permission to do the procedure. Read the form carefully and ask questions if something is not clear.

• You’ll have a physical exam to make sure you are in good health before having the procedure. You may have blood or other tests, such as an electrocardiogram for the heart and chest X-rays for the lungs. You may also meet with a dietitian and often a mental health counselor.

• You will be asked to fast for 8 hours before the procedure, generally after midnight.

• If you are pregnant or think you might be, tell your healthcare provider.

• Tell your healthcare provider if you are sensitive to or are allergic to any medicines, latex, iodine, tape, or anesthesia.

• Tell your healthcare provider of all medicines (prescription and over-the-counter) and herbal supplements you take.

• Tell your healthcare provider if you have a history of bleeding problems. Also tell them if you are taking any anticoagulant (blood-thinning) medicines. These include warfarin, aspirin, ibuprofen, naprosyn, or other medicines that affect blood clotting. You may need to stop these medicines before the procedure.

• You may be asked to start exercising and change your diet a few weeks before surgery.

• If you are a woman of childbearing age, you may get birth control counseling so that you don't become pregnant in your first year after surgery. Rapid weight loss can harm the fetus.

• You may be given a sedative before the procedure to help you relax.

• Based on your medical condition, your healthcare provider may request other specific preparation.

What happens during gastric restrictive surgery?

Restrictive gastric surgery sometimes needs a stay in the hospital. Procedures may vary based on the type of procedure done and your healthcare provider.

These operations need you to be asleep under general anesthesia. Your healthcare provider will discuss this with you before surgery.

Generally, the following process happens:

1. You will be asked to remove clothing and will be given a gown to wear.

2. An IV (intravenous) line will be started in your arm or hand.

3. You will be positioned lying on your back on the operating table.

4. If there is excessive hair at the surgical site, it may be shaved off.

5. A urinary catheter will be inserted.

6. The anesthesiologist will keep track of your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.

7. The skin over the surgical site will be cleaned.

8. For a laparoscopic procedure, a series of small incisions (usually ½ to 1 inch long) will be made. For an open procedure, the surgeon will make a single larger incision in the stomach area. Carbon dioxide gas is pumped into the belly (abdomen). This inflates the abdominal cavity so that the stomach and intestines can easily be seen.

9. For a laparoscopic adjustable gastric band procedure, a band is placed around the top end of the stomach encircling it to create the small pouch. A narrow passage through the band will connect to the rest of the stomach. The band will be inflated with a salt solution.

10. For a vertical sleeve gastrectomy procedure, about 80% of the stomach will be removed, and a small sleeve of the stomach will be created with a line of staples.

11. A drain may be placed in the incision site to remove excess fluid.

12. The incision(s) will be closed with stitches or surgical staples.

13. A clean bandage or dressing will be applied.

What happens after gastric restrictive surgery?

You will be taken to the postanesthesia care unit after the procedure to be closely watched as you wake up from anesthesia. You will be taken to your hospital room once your blood pressure, pulse, and breathing are stable and you are alert.

You may get pain medicine as needed. This will be either from a nurse or by giving it yourself through a preprogrammed pump device connected to your IV line.

You will be encouraged to move around while you are in bed, and then to get out of bed and walk around as your strength improves. The first time you get up, ask the nurse to help you, so you don't fall or faint. It's important for you to move around soon after your surgery to prevent blood clots.

At first, you will get fluids through an IV. That evening or the next day, you will be given liquids, such as broth or clear juice to drink. As you are able to take liquids, you may be given thicker liquids, such as pudding, milk, or cream soup. This is followed by foods that you do not have to chew, such as hot cereal or pureed foods. Some surgeons recommend a liquid diet for 1 to 2 weeks. Your healthcare provider will instruct you about how long to stay on a liquid diet and when it's time to progress to eat pureed foods after surgery. By 4 to 6 weeks after your procedure, you may be eating solid foods.

Pay attention to the size of the portions. Follow your surgeon's or dietitian's advice on what to eat, how much to eat, and how often. This will help you to lose extra weight.

You will be instructed about taking nutritional supplements to replace the nutrients lost due to the reconstruction of the digestive tract. You will also be encouraged to maximize protein intake, often with protein drinks.

Before you are discharged from the hospital, follow-up visits are arranged.

When should I call my healthcare provider?

Report any of these symptoms to your healthcare provider immediately:

• Fever or chills

• Redness, swelling, or bleeding or other drainage from the incision site

• Increased pain around the incision site

• Chest pain or trouble breathing

After surgery, your healthcare provider may give you other instructions, depending on your situation.

Once you are home, it will be important to keep the surgical area clean and dry. Your healthcare provider will give you bathing instructions. The stitches or surgical staples will be removed during a follow-up visit in a week or so.

The incision and stomach muscles may ache, especially with deep breathing, coughing, and exertion. Take a pain reliever for soreness as advised by your healthcare provider. Aspirin or certain other pain medicines called nonsteroidal anti-inflammatory drugs may increase the chance of bleeding and for ulcers to form in the stomach. Take only recommended medicines.

Keep up the breathing exercises used in the hospital to prevent lung infections.

Gradually increase your physical activity as you are able. It may take several weeks or months to return to your previous levels of stamina.

You may be told to stay away from lifting heavy items for a few weeks to months, depending on whether the operation was done laparoscopically or with an open method. This will help prevent strain on your stomach muscles and surgical incision.

Weight loss surgery can be emotionally difficult because you will be adjusting to new dietary habits and a body in the process of change. If your feelings are serious enough to interfere with daily functions, consider getting short-term counseling. Your surgical team can suggest resources.

You may feel especially tired during the first 4 to 6 weeks after surgery. Following the prescribed postsurgery exercise program and going to a support group may be helpful at this time.

Next steps

Before you agree to the test or procedure make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure

• Who will do the test or procedure and what that person’s qualifications are

• What would happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how you will get the results

• Who to call after the test or procedure if you have questions or problems

• How much you will have to pay for the test or procedure