A Comprehensive Guide to Postoperative Management of Gastric Banding: Weight Loss Plan from Anesthesia to Follow-up

Gastric ligation:

This surgery is used to treat obesity exceeding 20% ​​of body weight.

Postoperative management:

1. Anesthesia: Regional anesthesia is preferred whenever possible, as it avoids concerns about difficult intubation, aspiration of gastric contents, and liver damage. For abdominal surgery, combined epidural anesthesia is preferable to general anesthesia alone, reducing the dosage of muscle relaxants and opioids; it allows for maintenance anesthesia with low-concentration general anesthetics; it allows for earlier extubation; it reduces postoperative pulmonary complications; and postoperative analgesia can be administered via epidural injection.

During anesthesia induction, the head, shoulders, and chest should be elevated. Patients with morbid obesity should be prepared for difficult intubation; awake intubation or fiberoptic bronchoscopy-guided intubation should be used whenever possible. Pure oxygen must be administered for 3 minutes before intubation. If there are no contraindications, ultra-short-acting propofol can also be used.

Anesthesia maintenance should employ balanced anesthesia, commonly using a combination of enflurane or isoflurane, opioids, non-depolarizing muscle relaxants, and epidural block. Short-acting opioids should be used, avoiding morphine. For epidural block, lidocaine, with its rapid onset, can be used initially, followed by long-acting bupivacaine for maintenance. Tidal volume needs to be increased, calculated at 15-20 ml/kg based on ideal body weight. PEEP should be used as needed based on the patient's oxygenation, post-expiratory CO₂ concentration, and CO.

2. Postoperative Analgesia: Intramuscular injection of opioids often fails to achieve the desired analgesic effect in obese patients and is therefore not recommended. Intermittent intravenous opioids can be administered, but the specific pharmacokinetic changes should be carefully monitored, and the dosage should be calculated based on ideal body weight rather than absolute body weight. Local anesthetics or opioids can be administered via an epidural catheter for analgesia. Epidural injection of bupivacaine provides analgesia and cardioprotection comparable to intravenous morphine.

3. Postoperative Care
Postoperative care follows standard surgical protocols, with emphasis on prophylactic antibiotics and monitoring of vital signs, electrolyte balance, and glucose metabolism.

The first 24 hours postoperatively are critical, as severe anastomotic leakage or intra-abdominal infection may occur during this period. If the pulse exceeds 120 beats/minute, body temperature rises above 38.5°C, or the patient develops a sickly appearance, emergency surgical exploration or additional antibiotics are necessary. Barium swallow may help with anastomotic leakage, but it is not entirely reliable. Ignoring perforation or intra-abdominal infection can lead to death. If anastomotic leakage is suspected, surgical exploration should be performed as soon as possible, as it is safer than ignoring perforation.

The patient should be in the ICU on postoperative day 1 and can be transferred to the surgical ward thereafter. Postoperative pulmonary complications are common, especially in patients with pre-existing respiratory diseases; the complication rate can reach 33%, compared to only 12% in those without respiratory diseases. Postoperative pulmonary function decline should last at least 5 days. Preventive measures should be taken, including maintaining a semi-recumbent position for several days post-surgery; nebulized inhalation; initiating chest therapy as early as possible; using nasal continuous positive airway pressure (CPAP) at night to prevent airway obstruction; and extubation only after the patient is fully awake.

Post-operatively, the patient should fast for 3 days. On the 4th post-operative day, 30ml of half-concentration elemental diet should be given three times a day; 30ml of water should be consumed every hour. From the 5th to the 7th post-operative day, 30ml of full-concentration elemental diet should be given three times a day; 30ml of water should be consumed every hour. A liquid diet should be maintained for 1-2 weeks post-surgery. A normal diet should gradually begin 2-6 weeks post-surgery. Most patients return to their previous eating habits, but due to a feeling of fullness and slowed gastric emptying, food intake is significantly reduced. Three months post-surgery, most patients have reduced food intake but maintain a good dietary balance.

4. Long-term follow-up: Patients should be informed of the importance of long-term follow-up before surgery. Post-operatively, vitamin supplementation is particularly emphasized; insufficient intake can lead to anemia, amnesia syndrome, or other neurological disorders. Close monitoring of glucose tolerance, blood pressure, and patient mood is crucial. If weight regain exceeds 12% of the postoperative minimum weight, it may be due to staple dislodgement, anastomotic dilation, or compensatory overeating. Abdominal pain is most commonly caused by cholecystitis, but in some patients it is due to anastomotic ulceration, which can be treated with H₂ receptor antagonists. Secondary vomiting can be caused by overeating or stenosis between the gastrojejunostomy and anastomosis; anastomotic stenosis can be relieved after 1-2 dilation procedures.

In summary, morbid obesity is a serious disease with an increasing incidence rate. Its complications include diabetes, hypertension, biliary tract disease, and arthritis, all of which severely impact health and lifespan. Since diet, exercise, and medication are often insufficient to produce sustained and effective weight loss in morbid obesity, surgical treatment has become an important option. To date, gastric bypass and gastrectomy have become relatively mature surgical procedures with satisfactory treatment results. Although the surgery is challenging and patient management is complex, it is a worthwhile surgical treatment for morbidly obese patients. Long-term follow-up is crucial to prevent nutritional deficiencies and psychological problems. Although occasional postoperative complications such as gastric sac enlargement, anastomotic dilatation, and anastomotic pin dislodgement may occur, satisfactory treatment results can be achieved with repeat surgery.