Monday, 18 April 2011

Adjustable Gastric Banding - Information for Patients

Today, the adjustable gastric banding LAP-BAND® is one of the most popular methods of restrictive weight loss (bariatric) surgery. The technique has been specifically designed for obese or morbidly obese patients who generally have a body mass index (BMI) over 35. The band can be used in the majority of people wishing or needing to loose weight and bands have been successfully applied to patients with BMIs as high as 99.
Weight loss surgery improves many of the co-morbidities associated with obesity such as sleep apnoea, diabetes, osteoarthritis, gastro-oesophageal reflux disease (GORD), Hypertension (high blood pressure) and metabolic syndrome. In patients with these associated conditions, minimally invasive low risk surgery is the treatment of choice.
Patients who undergo adjustable gastric band surgery can expect to lose more than 60% of excess body weight. Typically, patients who undergo adjustable gastric banding procedures lose less weight over the first 3.5 years than those who have gastric bypass, or other surgeries such as Biliary-pancreatic Diversion (BPD) or Duodenal Switch (BPD-DS) (see later).

However after 4 years, the weight loss from gastric banding and bypass are essentially equal according to the American College of Surgeons. Most patients achieve 65 to 90% of their ideal excess weight loss, but in order to fully maximise and maintain this degree of weight reduction patients should follow the post-operative diet, exercise, and band maintenance guidelines.

Laparoscopic gastric banding surgery was first introduced in the early 1990s and since then it has become the most widely used weight control surgery in a number of countries. In some countries gastric banding has been slow to catch on and surgeons have tended towards by-pass operations but statistics for the last 2 years have shown a huge shift in preference towards the band, mainly because of the improved surgical techniques and very low complication rates.
The main benefit of gastric banding surgery is that it does not require the removal or division of any part of the patient’s digestive system. Furthermore the band can be removed without any long term problems, but this does require a further keyhole surgery procedure. Once the LapBAND has been removed, the stomach usually returns to its normal pre-banded state over time without any known problems to date.

The LAP-BAND® appliance itself is an inflatable prosthetic medical device which is placed around the top section of your stomach via a 45 – 90 minute minimally invasive operation using a small laparoscopic camera and 4 or 5 small incisions in the tummy.  This minimally invasive surgical technique results in less discomfort and time off work than traditional open abdominal surgery and these days the operation is often performed as a “day case” procedure.

A tube runs from the band to a small filling port which is placed under the skin on the abdominal wall. Once the gastric band is in situ around the top part of your stomach it creates a small pouch at the upper end of the stomach which is designed to hold approximately 50mls of content. This “neo-stomach” fills with food quickly as you eat and empties slowly because the outflow into the rest of the stomach and intestinal tract is restricted by the LAP-BAND®. When full the small “neo-stomach” sends subconscious messages to brain receptors that the stomach is full and this helps you to learn to eat smaller portions of food and fluids, which ultimately over time results in the required weight loss.
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Following the operation you will have a 4-6 week settling down period to allow any operative swelling to settle. The filling port under the skin allows for the size of the band to be increased or decreased by your surgeon. This is achieved by introducing saline into the band to gradually increase the gastric restriction. Unlike by-pass surgery, laparoscopic gastric banding does not involve cutting or stapling of the stomach or intestines, which means there is much less change of operative complications and also meaning that the operation can be reversed if necessary.

LAP-BAND® Adjustable Gastric Banding System

Benefits of gastric banding when compared to other bariatric operations

  • Lower mortality rate: only 1 in 2000 for the LAP-BAND® versus 1 in 250 for Roux-en-Y gastric bypass surgery, or other surgeries such as Biliopancreatic Diversion (BPD) or Duodenal Switch (BPD-DS)
  • Fully reversible: stomach returns to normal if the band is removed
  • No cutting or stapling of the stomach
  • Short hospital stay
  • Quick recovery
  • Adjustable without additional surgery
  • No malabsorption issues (because no intestines are bypassed)
  • Fewer life threatening complications (see complications table for details)

Indications and Contraindications for LAP-BAND® insertion
In general, gastric banding is indicated for people for whom all of the following apply:
  • Body Mass Index above 35, or those who are 45 kilograms or more over their estimated ideal weight according to the 1983 Metropolitan Life Insurance Tables or those between 35 to 40 with co-morbidities which may improve with weight loss (high blood pressure, diabetes, sleep apnea, and arthritis).
  • Age between 18 and 65 years.
  • Failure of dietary or weight-loss drug therapy for more than one year.
  • History of obesity (generally 5 years or more).
  • Comprehension of the risks and benefits of the procedure and willingness to comply with the substantial lifelong dietary restrictions required for long term success.
  • Acceptable operative risk.
It is usually contraindicated for people with any of the following:
  • If the surgery or treatment represents an unreasonable risk to the patient.
  • Untreated endocrine diseases such as hypothyroidism.
  • Inflammatory diseases of the gastrointestinal tract such as ulcers, oesophagitis or Crohn’s disease.
  • Severe cardiopulmonary diseases or other conditions which may make them poor surgical candidates in general.
  • An allergic reaction to materials contained in the band or who have exhibited a pain intolerance to implanted devices.
  • Dependency on alcohol or drugs.
  • People with severe learning or cognitive disabilities or emotionally unstable people.

How does the Gastric Band Work?
The laparoscopic gastric band assists weight loss and weight control in two ways:
  1. Creating a sense of fullness. The band presses on the stomach, which makes the brain think that the stomach is full and therefore requires no more food.
  2. Satisfying hunger sooner. The band creates a smaller stomach pouch, so that less food is required to feel satisfied. Also, because the band has reduced the size of the passage through which food passes, it takes longer to digest.
For best results you will require long term support from your Health professional team at the Specialist Medical Clinic who are available to provide long-term support for you.
Our team consists of a surgeon, an endocrine specialist, a dietician, and an exercise expert.

How is the band adjusted?
The gastric banding is inflated and adjusted through the small access port which is located just under the surface of the skin in the upper abdominal area. Often this is readily achieved but in some patients this needs to be done using ultrasound guidance. A solution of saline is introduced into the band via this port. The band is filled using a specialized surgical needle which is necessary to avoid any damage to the port membrane.
Adjustments must subsequently be undertaken by a qualified gastric banding Surgeon or one of his assistants who have been specially trained in this procedure. The port is generally stitched into place to maintain the stability of the portal access point, and also to avoid any accidental damage by the Patient in their normal every day life.

When fluid is introduced into the band, the band is inflated further, and as it expands it places additional pressure around the outside of the banded stomach area. This then decreases the size of the passage between the two areas of the stomach thereby restricting the movement of food into the lower part of the stomach.

Optimizing your weight loss through adjustments
Being able to adjust the LAP-BAND® gives you and your surgeon complete control over your weight loss progress. If the LAP-BAND® is too tight, your surgeon can loosen it by taking out some of the fluid. If the LAP-BAND® is too loose, it can be tightened by injecting fluid into your access port.
Only a suitably trained clinician should adjust your LAP-BAND® System. Never let an untrained clinician or a non-medical person do it, and never try to adjust your own LAP-BAND® System.
When the LAP-BAND® is first placed, it will be left empty or only partially inflated. This allows your body the chance to get accustomed to your LAP-BAND® System during the first few weeks after surgery whilst healing is occurring around the operation site. It's critical during this time to avoid vomiting and/or putting any pressure on your new small stomach above the band.
The LAP-BAND® is usually adjusted four to six weeks after surgery, although the exact time will vary from patient to patient. A number of adjustments will necessary to ensure that you are placed into the weight loss “Green Zone” and during the first year, most patients get between five and eight adjustments. Sometimes, small adjustments (as little as ½ ml) are necessary over the years in order to maintain weight loss at a steady rate and keep you in the “Green Zone”.
During an adjustment, the surgeon will use a fine needle to inject or withdraw fluid from your access port, which is located under your skin. Local anaesthetic is used to minimise the slight discomfort experienced by some patients. The feeling is similar to the pinprick you feel when you give blood. Sterile saline (salt water) is used to adjust the LAP-BAND®.
Adjustments are done either in the surgeon's office or hospital using a palpation method (simply pressing down on the skin to locate the access port) or ultrasound. In some very difficult cases it may be necessary to use fluoroscopy (x-rays) to guide the needle into the port or to evaluate your pouch size and stoma size after the adjustment. As you take a drink of a special liquid (usually called barium), your surgeon will be able to watch it travel down your esophagus into the small upper stomach pouch, through your stoma, and into your big lower stomach.
To get the best results, you may need more than one adjustment. The most common reasons for adjustments are not being able to eat without feeling uncomfortable or vomiting, being able to eat too much without feeling full, or not losing weight.

Getting into "The Green Zone"
The LAP-BAND® System Journey is different for each person and the exact amount of fluid required to make the new stomach opening the right size is unique for each patient. An ideal "fill" level should be just tight enough to let you gradually lose weight. That means you should still be able to eat enough to get the nutrients that you need, while still reducing the overall amount you can actually eat.  This is called the “Green Zone”.

Over the course of 4 or 5 post op visits, the band is filled until you feel that you have found "green zone". This is where optimal restriction has been achieved, neither so loose that hunger is not controlled, nor so tight that food cannot be consumed. This is an individual experience and cannot be predicted. Depending on which band size you have placed, the total volume of saline that can be placed in the band can be as much as 14mls.

Potential Complications Associated with Gastric Banding

Whilst the LapBand is a very safe device, like all operations there is a risk of complications occurring. Whilst these are rare occurrences, this section covers the possible problems that can occasionally occur.  

Weight re-gain
Weight regain is possible as with ANY weight loss procedures including gastric banding. Whilst the operation is designed to reduce your energy intake, non adherence to the advice given by your team will minimise the effectiveness of the LapBAND.

The World Health Organization recommends that a weight loss rate of ½ to 1 kilograms per week should be a general target weight loss for the average Gastric banding patient. Weight loss rate is however very variable and generally the rate of loss and total weight loss is very dependent on the personal attitude and determination of the individual patient, their life circumstances and their mobility.

Productive Burping
A commonly reported occurrence for gastric banding patients is regurgitation of non-acidic food from the upper pouched area. If the gastric banding Patient experiences this regularly, then they should consider eating less, eating much slower, and chewing their food much more thoroughly. If this does not eventually solve the problem then further medical advice must be obtained from your team at the Specialist Medical Clinic.

Occasionally, the narrow passage at the Banded area of the stomach can become blocked by a large piece of un-chewed or unsuitable food. If this occurs on a regular basis then further adjustments to your diet should be considered, and once again you are strongly advised to consult your gastric banding Reactionary or dietician.

Slippage of the gastric Band is now also an unusual occurrence. This when the lower part of the stomach may prolapsed over the band devices and cause an obstruction. This was one of the reasons why some surgeons preferred to offer by-pass surgery but recent design changes and modification of the operative technique now means that this is a very rare occurrence. Warning signs are usually noticed well beforehand.

Ulceration and Gastritis
The change in the exposure of the antrum (lower) part of the stomach to food may lead to a degree of unopposed acid secretion which may in turn cause some gastritis and possible ulcer formation. Your doctor will prescribe some treatment for this should it occur.

Mechanical malfunctions
Occasionally the system fails and there is leakage of fluid from the port or cracking of the kink-resistant tubing or disruption of the tubing connection from the port to the band.

Port site pain or displacement
Sometimes the subcutaneous port can move or change its position, especially as there is increased weight loss, or the port is placed near to the rib cage. If the post becomes painful or it becomes very difficult to fill the band, then it may be necessary to re-site the port. This can be done relatively easily and your surgeon may choose to replace the port in the process.

Infection of the fluid within the band
The band is filled with sterile saline, however sometimes the fluid can become infected. If the infection cannot be overcome, it may be necessary to replace the band.

Nutritional deficiencies
Unlike bypass operations, it is very unusual for gastric banding patients to experience any nutritional deficiencies following gastric band surgery (e.g. Roux-en-Y gastric bypass surgery (RNY), Biliopancreatic Diversion (BPD) and Duodenal Switch (DS)). "Gastric dumping syndrome" (a feeling of nausea and sweating after eating food) issues also do not occur with gastric banding surgery, since no parts of the intestines or indeed of the stomach need to be removed or re-routed.

Erosion and migration
Very rarely the wear and aggravate a small area on the outside of the stomach wall which can then, in very rare and extreme cases, lead to a migration of the band itself into the inside the stomach. This however is a very very rare occurrence and usually there are many warning signs well in advance of this ever happening.

Psychological Effects
Psychological effects of any weight loss procedure must also be considered. Many Patients who have been Obese for extended periods of time prior to the gastric banding surgery procedure, have habitually overeaten for a greater part of their lives, therefore any sudden changes to their diet and lifestyle can have some adverse affects on the Patient.

Recent studies show that the gastric band can have a positive effect on depressive patients. Two groups of 600 overweight patients, (BMI greater than 40), were closely watched for five years post band insertion. Both groups initially had about 29% depressive patients. After six months, both groups were less depressed but after five years, the number of depressive patients in the non-operated control group had returned to its origin, while members of the operated group were noticeably less depressed.

Blood Clots / Thrombosis
All patients undergoing surgery are at increased risk of developing blood clots in the calves or legs. In order to minimise this, you will receive an injection to thin the blood during your operation.

Despite this prophylactic treatment, you may develop a clot, so if you develop pain in the calf or chest pain in the days following your operation you should contact the Specialist Medical Clinic team. 

Special Circumstances


The LAP-BAND®  should not be placed during pregnancy however pregnancy itself does not mean that a band needs to be removed.

If considering pregnancy, ideally you should be in optimum nutritional condition prior to, or immediately following conception. Therefore deflation of the band may be advised or required prior to a planned conception. Deflation should also be considered should morning sickness be present. It may be possible to continue to loose weight during pregnancy by leaving the band inflated, however your weight loss team will need to liaise closely with your obstetrician to ensure that you or the foetus do not become malnourished during the pregnancy.
The band may remain deflated during pregnancy and once breast feeding is completed, or if bottle feeding, the band may be gradually re-inflated to aid postpartum weight loss as needed.

Recommended Diet After Gastric Banding
To gain the maximum benefit from your LapBAND, you will need to make some significant lifestyle changes. It is imperative that you follow the recommended pre- and post-surgery diets below to maximise the chances of success of your LapBAND. Your weight loss program will be overseen by our dietician. 
Immediately post-surgery (0-2 Weeks)
In the two weeks following your operation, you should have a fluid only diet (this means liquids that you can drink through a straw). This will ensure optimum healing around the surgical site. During this period you should follow the guidelines below. They have been devised to ensure that you get a balanced intake of protein, energy, carbohydrate and trace elements thus ensuring that you recover from your surgery as quickly as possible.
·         Take daily liquid or chewable multivitamins and calcium supplements (e.g. Centrum Chewable and Sanatogen Gold). Ask your local pharmacist about medications that you can take in liquid form.
·         Drink 2.5 to 3.5 litres every day divided evenly throughout the day. The best way to determine if you’re properly hydrated is through your urine. Pale urine means you are drinking enough. In contrast, darker urine indicates dehydration and a need for more liquids. Drink at least 200 ml of fluids with every intake. Try to drink one pint (600 ml) of fortified semi-skimmed milk daily. Other acceptable “safe” fluids include fortified soups, low-calorie diluted fruit juice (1 part juice to 1 part water), herbal teas and coffee and water.
·         Avoid carbonated drinks. The band will prevent you from regurgitating gas and air and this will result in bloating and distension of your stomach wall, thereby causing your gastric band to slip.
·         Do not chew gum.
·         Feeling hungry during this period is normal. This is usually caused by stretch receptors in your stomach that have been triggered by surgery. The sensation will pass eventually so you just need to stay motivated.
2 to 4 Weeks following surgery: Soft diet and good fluid intake as above
You can now start taking in soft food. Your meals should have the consistency of cottage pie, scrambled egg, or well-cooked cauliflower. You want food that you can easily mash using a fork. Avoid crunchy food and salads for now.  Suggested foods include:-
Lunch / Dinner
Scrambled or poached eggs
Porridge (semi skimmed milk)
Thick fruit smoothies (Blend fruit with skimmed milk or low-fat yoghurt)

Fish pie with pureed vegetables
Minced meat casserole
Vegetable soups
Soft pasta plus tomato sauce
Cottage cheese (low fat)
Soft boiled egg / mashed avocado
Mashed potatoes and poached salmon
Pureed vegetables
Stewed or pureed fruit
Mashed banana
Sugar-free jelly and sorbets

4 weeks onwards
Four weeks after having your LapBAND inserted, the swelling around the stomach should have settled and you can begin to return to a more normal texture diet.
There will be a number of differences from your pre surgery eating habits and by this time, you will have had your first session with our dietician who will help you to plan your meals and monitor your progress.
Examples of food that you can now eat include:-
Lunch, Dinner, Snacks
Small banana with low-fat yoghurt
Whole grain toast and sugar-free jam or fruit puree
All bran flakes and cereal bars
Fruit salad

Cottage cheese
Pasta, rice, and noodle
Salmon with cucumber
Tuna and baked beans or onion
Egg salad
Potato salad with low-fat dressing
Roast sweet potato

Additional Important Information
    • You should wait at least 1 hour after drinking before you start eating a meal
  • Your portion sizes are going to be much smaller than before the operation. Psychologically it is quite useful to place your meal on a small (side / tea) plate or child’s plate.
    • This is more than enough to fill your “new” stomach and you will learn to feel full after this reduced sized meal.
  • LIMIT YOUR EATING TIME TO A MAXIMUM OF 20 MINUTES ONLY. Any food remaining on the plate after this time should be discarded
  • Before meals, you should drink a lot of fluids and wait at least an hour after meals before you drink again.
  • CHEW YOUR FOOD THOROUGHLY AND EAT SLOWLY. Try to chew at least 20 times every mouthful. This is particularly important when you are eating bread, rice, chicken, or any other form of meat. If not properly chewed, these foods can stick in the outlet of the new stomach and lead to obstruction.
  • You should not require any vitamin or mineral supplements at this stage
  • Do not drink carbonated drinks or chew gum.
  • Take up a regular exercise regime
  • It is good to get into the practice of recording your food intake, exercise and weekly weight in a food diary so you can monitor your progress.