Management and nutritional assessment of common postoperative complaints after LAGB surgery

Adjust the radiographic criteria for bandaging: Consider draining fluid (outlet narrowing; esophageal dilation >2 times; esophageal atony; esophageal emptying barium meal >4-5 peristaltic waves; gastric pouch dilation with inadequate emptying); consider increasing the injection volume (outlet too large >8mm; immediate barium meal 1 peristaltic wave; reflux).

These signs and symptoms have been used in a clinical pathway designed by the NYU Bariatric Surgical Program and are used as a general guideline.

After each adjustment, the patient needs to drink a glass of water to ensure that there is no obstruction at the outlet.

Any hiccup sound may indicate an obstruction in the next 1 to 3 days.

Interestingly, we found that the straps became slightly tighter after 1 to 3 days of adjustment.

Therefore, we had the patient eat a clear liquid diet for 2 days after adjustment, followed by a semi-liquid diet for 2 days, and then a soft solid diet on the 5th day after adjustment.

However, radiographic imaging can confirm outflow obstruction, esophageal dilatation, gastric pouch dilatation or prolapse, acid reflux, and ineffective or incorrectly placed bandages.

These situations require immediate intervention, such as loosening the bandages.

This is sometimes important because not all abnormalities will present with clinical symptoms.

Busetto et al. found that among 379 LAGB patients, the average number of bandage adjustments in the first year after surgery was 2.3 ± 1.7 times, and the average maximum infused volume after surgery was 2.8 ± 1.2 ml.

Although using radiographic imaging to assist in bandage adjustment requires far fewer follow-ups and adjustments, it demands significantly more expense and effort.

Surgeons must coordinate the use of X-ray machines with the radiology department; this can be time-consuming and expensive, unless the surgeon has a C-arm X-ray machine in their office.

Each adjustment takes 15 to 20 minutes.

Large medical centers can reduce this time to 10 minutes.

In addition, because patients require fewer follow-up visits, they do not receive repeated emotional support from healthcare professionals.

Chief complaint and symptoms

At New York University, we perform bandage adjustments in outpatient settings and follow up with patients every 4–6 weeks to assess their weight and appetite.

The purpose of this project is to allow patients to undergo routine weighing, condition assessment, bandage adjustment, nutritional fortification, and behavioral counseling.

We found that the frequency of follow-up had a significant impact on the percentage of excess weight loss (%EWL) in the first year after surgery.

Patients who had more than 6 follow-up visits in the first year after LAGB surgery had an %EWL of 50%, compared to only 42% for patients who had 6 or fewer follow-up visits.

The average number of adjustments in the first year was 4.5, and in the second year it was 2.

The average amount of liquid remaining in the bandage after the first year was 1.9 ml.

This relatively low volume may be due to the smaller diameter of the bandage opening that can be achieved with surgical techniques for loosening the skin.

To cope with the surge in outpatient visits caused by frequent postoperative follow-ups, we have hired a licensed nurse specifically for these patients.

This not only allows for more optimized adjustment of the patient's gastric bandage, but also enables the patient to receive more behavioral guidance and emotional support at each follow-up visit.

Difficulty swallowing solid foods is the most common postoperative complaint.

This is often associated with the following behaviors in patients: ① eating too quickly; ② forgetting that they have a gastric bandage; ③ eating foods that are difficult to chew, especially steak; ④ eating foods that are easy to coagulate, such as white bread; ⑤ experiencing anxiety or anger while eating.

Some patients fail to learn from their unpleasant eating experiences after surgery and continue to persist with incorrect eating habits.

Chest pain caused by esophageal obstruction occurs every time, which is very painful for patients and difficult for doctors to manage.

Food can cause narrowing of the bandage opening, leading to pain.

Initially, the severe chest pain and drooling terrified the patient.

Once patients realize this, their anxiety will be greatly reduced.

The simplest solution is to induce vomiting, which can release the obstruction.

What actually happens during this process is regurgitation, not vomiting.

Patients will directly experience the relief of pain.

The patient should only consume liquids for the remainder of this meal, as mucosal swelling may occur within the bandage.

Carbonated drinks should be avoided to release the obstruction, as the expansion of gas within the obstructed esophagus can cause severe pain.

Repeated reflux or vomiting can cause local mucosal edema in the reflux site. It is recommended that patients consume only liquid food for 24 hours after the above-mentioned situation occurs.

If food remains stuck in their throat and they cannot tolerate any liquid, even their own saliva, they should seek medical help.

The bandage needs to be loosened immediately to remove all the saline solution from the bandage, allowing the obstructing food bolus to pass through.

The straps can be readjusted after 2 days.

Difficulty swallowing and reflux are usually most pronounced in the morning, improve throughout the day, and are rarely seen in the evening.

This is related to the diurnal variation in esophageal activity.

For many patients, it is best to have a liquid diet for breakfast, such as a cup of coffee and a protein shake, so that they can drink it slowly on their way to work.

This greatly reduces morning stress.

Explaining these mechanisms can effectively help patients understand the difficulties they encounter and alleviate their fear of past weight loss failures.

Difficulty swallowing is definitely influenced by emotional factors.

A very important group is young people who are dating, whose newly built confidence after losing weight can be destroyed by being seen having difficulty eating or vomiting.

These young people need special advice: have a small alcoholic beverage before a date to help them relax; choose foods that suit them, such as soup, onion risotto, or thinly sliced ​​fish; and resist the pressure to eat more.

They should eat slowly, and drink some wine while eating, just like normal people.

This allows them to connect with their friends and date more comfortably.

Acid reflux can occur in the following situations: ① the bandage is too tight; ② the bandage slips off, causing gastric prolapse; ③ there is a neglected hiatal hernia.

These are not clinically distinguishable, but can be diagnosed through esophagography.

Proper treatment may involve draining the fluid from the bandage, surgically repositioning the bandage, or reducing or repairing a hiatal hernia.

The most severe cases are nighttime reflux and acid reflux, which usually manifest as insomnia, accompanied by initial asthma, or even aspiration pneumonia.

This is more common in patients with gastric prolapse or slippage of the ligament.

Nutritional assessment

Because LAGB only restricts the patient's food intake, no postoperative malnutrition problems have been found so far.

However, we will conduct a comprehensive laboratory test on patients once a year, including iron, folic acid, vitamin B₁, vitamin B₁₂, parathyroid hormone, and calcium.

We found that two young women developed iron deficiency one year after surgery, and one young woman developed vitamin B₁₂ deficiency.

The implications of this result, especially for young menstruating women, are inconclusive, as these laboratory tests were not performed prior to the procedure.

Patients who cannot tolerate the restriction of the gastric bandage and adopt poor eating behaviors need to have their gastric bandage removed and undergo modified gastric bypass surgery, which may provide greater benefits.

Consulting services

Patients should understand that achieving weight loss requires consistent follow-up and adherence to instructions.

They need to adjust their nutrition and activity levels.

In the long run, LAGB has similar effects to Y-shaped gastric bypass (RYGB).

Patients need to understand that they can only choose between maintaining their original food intake and eating habits and achieving weight loss after surgery. If they continue to eat the same way after surgery, they will not be able to achieve their weight loss goals.

After LAGB surgery, the restriction on food intake is achieved gradually, so the weight loss is also gradual.

Therefore, a planned and gradual approach is an effective way to achieve and maintain ideal weight loss.

Support group activities and psychotherapy can help patients adapt to reduced food intake, a new self-image, and changes in eating habits after bariatric surgery.

However, the most effective help for patients after surgery comes from the surgeon listening to them and patiently explaining the principles of postoperative diet.