GENERAL, LAPAROSCOPIC AND OBESITY SURGERY
OBESITY SURGERY CENTER, INC.
OSVALDO ANEZ, MD, FACS
DIPLOMATE OF THE AMERICAN BOARD OF SURGERY
462 Herndon Parkway, Suite 101, Herndon, VA 20170 · Phone 703-956-6743 · Fax 703-956-6749
INFORMED CONSENT FOR PLACEMENT OF ADJUSTABLE GASTRIC
BANDING FOR OBESITY
Adjustable Gastric Banding placement for
obesity is an operation designed to separate the upper
end of the stomach into a small food “pouch” with a
capacity of approximately 2 ounces . The “pouch” is
still connected to the stomach but the channel is
narrowed by the band to a small outlet of about
1.0cm. (1/2”) in diameter. The Band functions by
limiting the amount of food or liquid, you can eat or
drink at one time. Since your intake will be
restricted, if you eat too much or too fast at once, you
may develop severe pain, vomiting, or both.
Obviously, it is possible to “beat the system” by
continuously drinking high calorie liquids (such as
melted ice cream, regular sodas, etc) and thus fail to
lose weight. However, if you eat a balanced diet at
normal meal times, and drink water, your caloric
intake will be reduced and you will lose weight.
Most patients lose one quarter of their starting weight
at the rate approximately 4 to 8 pounds per month
after surgery. Weight loss levels off and stabilizes at
an average of 30 to 40 % above the standard weight
for height, as determined by the metropolitan life
tablets, 1983.
Surgery for obesity involves major surgery
and has risks and potential complications, which
you must be aware of before your operation. As with
all surgeries, these include heart and lung problems,
bleeding, infection, pancreatitis and blood clots in
the legs and lungs. These complications are more
common in obese patients. There are other
complications specifically related to gastric
banging placement. The spleen lies close to the
upper end of the stomach where your surgery is
performed, injury to the spleen is possible
and removal of the spleen may be necessary. This
is an infrequent occurrence, however, happening in
less than 1% of patients. Very rarely, perforation of
the esophagus or stomach may occur due to the
proximity of these organs during band placement.
This serious complication requires immediate reoperation to close the perforation or repair the injury.
Injury to the vagus nerves to the stomach is a
possibility, since these nerves control the rate of
stomach emptying; this may result in delayed
emptying of the stomach. Again, these complications
are uncommon.
Technical problems with the band may occur: (A)
Gastric prolapse is a condition in which the lower
stomach can slide up through the band causing partial
or complete obstruction to the outlet. Band slippage
can also cause partial or complete obstruction to the
outlet. These conditions can cause severe pain and/or
vomiting can constitute a surgical emergency; (B)
Erosion of the band can occur when the band wears
through the stomach wall.
This is a surgical
emergency and requires that the band be removed.
(C) Mechanical obstruction can occur if the band is
too tight. (D) Rare cases of band leakage have also
been reported.
Wound infections and wound hernias are more
common in obese patients. Minor wound infections
have been reported in approximately 10% of patients
following surgery for obesity. In a few patients, these
complications result in poor wound healing with
weakness of the wound, scarring, deformity, pain, and
may even require re visional surgery for their
correction.
The mortality rate of adjustable gastric banding is
less than 1% but both you and your family should
realize that gastric banding is major surgery and that
complications of this procedure can be fatal.
The restriction of the stomach following gastric
banding does result in diminished intake of iron,
vitamins, vitamin B12 and calcium. As a result, late
development of anemia several years after surgery
may occur in some patients. Normal blood levels of
these can be maintained with vitamin and mineral
supplements. For this reason, it is essential to take
daily multivitamins and mineral supplements lifelong after the surgery, and to have regular follow-up
blood tests and medical check-ups on a long-term
basis. Following these guidelines for health is your
responsibility.
Because of these factors, there can be no
guarantee of the success of the surgery. There are
many alternatives in the
management of obesity,
particularly various dietary regimens, which carry
their own possible risks and complications and have a
varying degree of success. Surgical treatment is a
management alternative and should be considered as
such. It is not an absolute cure-all and does not affect
the underlying causes of obesity whether
psychological, physical, environmental, familial or
hormonal. In most cases, however, surgery is
successful in achieving weight loss.
Consent for Blood and Blood Product Transfusions.
1. I have had the opportunity to ask questions of the physician and understand the risks, benefits,
and alternatives involved in transfusion therapy.
2.  I consent to transfusion of all blood/blood products
 I consent to transfusion with the following exceptions:
 I refuse all transfusion and blood/blood products.
I HAVE READ OR HAD READ TO ME THE CONTESTS OF THIS FORM AND HAVE
RECEIVED A COPY. I UNDERSTAND AND THE RISKS AND ALTERNATIVES INVOLVED.
I HAVE NO FURTHER QUESTIONS AND WISH TO PROCEED WITH ADJUSTABLE
GASTRIC BANDING SURGERY.
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