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Preoperative Evaluation/Patient Issues/Laparogastric Gastric Banding

QUESTION:

Does anyone think that laparoscopic gastric banding is an acceptable procedure for a freestanding outpatient facility?

-- From Gerald Kranis, M.D., Miami, FL

REPLY:

Our group of 27 anesthesiologists has cared for 5500 bariatric patients over 5 years through 2003; 3000 were done in a full service 400+ bed hospital and 2000 at Fresno Surgery Center which is actually a 20 bed hospital. FSC has monitored beds in private rooms but no formal ICU. The vast majority of the procedures are laparoscopic gastric bypasses. The average LOS is 2 days. The transfer rate is extremely low and those transfers have not been for primary respiratory problems. None of the 2000 patients has required ventilatory support beyond very occasional CPAP.

Of the 2000 cases at FSC, I did 580 and 2 partners did 850 between them. We intubate under GA and SCH and need the difficult airway cart 1-2 times per year. We have concluded that BMI alone is not a limiting factor. The largest BMI was 85 and we routinely do patients with BMI's from 60-70. There are some co-morbid conditions that cause us to refer a patient to the larger institution. We assume that all patients have OSA and treat them accordingly. Most problems occur during the surgeon's learning curve (first hundred cases) and when the anesthesiologist is wedded to deep anesthesia with longer duration drugs. Extubation occurs only when patient can lift head, responds to commands and has appropriate VC. Average operating times are under 2 hours.

There are two procedures that have been discussed as outpatient procedures. They are the laparoscopic Roux-en Y gastric bypass (L-RYGB) and laparoscopic adjustable gastric banding (LAGB).

The L-RYGB procedure is the most accepted procedure by bariatric surgeons for weight loss. It is not generally considered an outpatient procedure. A series of 1000 outpatient L-RYGB's was recently presented. At first glance this series seems amazing but the "outpatient" stays included a 23 hour observation admission, which makes an actual LOS of 1-2 days depending on when one starts the 23 hour clock.

On the other hand, the LAGB is less invasive and could be done as an outpatient case with a number of caveats and considerations. The recent ASBS Meeting included a series of 700 LAGB's done as outpatients. While this operation does not involve bowel anastomoses, it is a major laparoscopic abdominal operation with its own set of complications such as esophageal injury.

Whatever procedure is done, it must be remembered that these are morbidly obese patients with a very high proportion having OSA and other co-morbid factors. Therefore the selection of anesthetic agents, technique and post-op analgesics is critical to safety and success. Our experience with obese patients has made us comfortable doing many as outpatients but it is still somewhat controversial and some centers still put these patients into an ICU setting overnight.

Our surgeons (three separate groups) all say that the LAGB is OK as an outpatient but it is not the best operation for obesity. They have also observed that the band was originally marketed to dedicated bariatric surgeons without overwhelming acceptance. It is now being marketed to the wider population of general surgeons who may not have the experience to furnish the required long-term support required in a bariatric program.

-- From Lou Freeman, M.D., Fresno, CA

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