Laparoscopic Adjustable Gastric Banding

Placement of a Laparoscopic Band is a fairly straightforward procedure that is accomplished by placing the Band, which is a belt-like section of plastic, around the upper stomach to create a tiny stomach pouch. The Band creates a calibrated narrowing at the bottom of this tiny new stomach, so that it is easy to fill up with small amounts of food.  This good sensation of fullness is called "satiety."
The key thing about the Band that is placed around the stomach is that it is adjustable. Adjustment is accomplished by means of a balloon that lines the inside of the Band. On the day of surgery, when the Band is placed, the balloon is empty and this provides only a slight restriction to eating. Over the weeks and months following surgery the balloon within the Band is gradually filled (outlet is tightened) to provide progressively increasing restriction that is matched or "tuned" to each patient.
The balloon adjustment is accomplished using an access port (which is buried under the skin) to increase or decrease the amount of saline fluid contained in the balloon. The Band is pictured in its normal position on the upper stomach at right.

There are several key features that make the Laparoscopic Band an attractive surgical technique for weight loss:

• laparoscopic placement
• no division or anastomosis of stomach or bowel
• removable
• adjustable

Laparoscopic Adjustable Gastric Banding

The first two of the features above probably reduce the risk of surgery, which is especially important when operating on patients who suffer from morbid obesity. The fact that there is no cutting or repositioning of any intestine brings the risk of leak or obstruction to very low levels (not impossible, as outlined in the risks section below). The fact that the procedure is almost always done laparoscopically may allow decreased stress on the vital organs (heart, lungs, etc.) and may allow quicker recovery in comparison to open procedures.
"Removable" in the list of key features refers to the fact that the Laparoscopic Band can be removed from the patient with little residual impact on the stomach. This seems to be true even when the band has eroded into the stomach, or become infected, or slipped out of position. This is possible because the silastic substance from which the band is made creates essentially no tissue reaction, so that the Band is not stuck in place over time. This feature also means that the Laparoscopic Band procedure is "reversible" in a certain sense. We hasten to clarify that the Band would only be removed in our practice because of medical necessity, and that if it were not replaced by some other weight loss procedure that the patient would be guaranteed to experience significant weight regain.
The feature of the Band that deserves the most attention is that it is adjustable. This is the feature that makes the Band (in many published reports) successful in helping patients achieve significant sustained weight loss. After all, if the Laparoscopic Band were not successful, then the decrease in operative risk would not mean much. As long as the patient and surgeon continue to work together, it is usually possible to adjust the Band to the patient's needs at that time.
There are several other potential advantages claimed by advocates of the Laparoscopic Band, which deserve mention.

• Slower weight loss - the Laparoscopic Band aims to create slower and steadier weight loss than the results seen after most other surgical procedures. Most weight loss operations create very rapid weight loss in the first few months, which then slows and stabilizes at 10-18 months after surgery. On the other hand, Laparoscopic Band patients begin with a relatively loose Band that allows ongoing intake of nutrition, and the Band is gradually "tightened" according to the patient's weight progress and satiety symptoms. This approach aims to achieve a weight loss of 1-2 pounds per week, that continues up to or beyond 30 months after surgery. Laparoscopic Band advocates promote this difference as "gentler" or "safer" or "more physiologic," but we have frankly seen very few nutritional problems in our many gastric bypass patients related to rapid weight loss.
• Nutrient Absorption - operations that involve rearrangement of the small intestine such as the gastric bypass or the BPD-DS create a deficiency of absorption of Iron, calcium and B12. Purely restrictive procedures such as the Laparoscopic Band should theoretically not cause such problems because no intestine is bypassed. Caution is needed, however; almost all VBG patients (outmoded operation) we see for surgical repair are deficient in Iron and B12. It may well turn out that the reduction in overall intake is more important than the specific bowel anatomy. In our practice for the time being, we are recommending exactly the same supplements after either the gastric bypass or the Laparoscopic Band.

Open questions

The Laparoscopic Band system has only been in use since the early/mid-1990's, so there is no data on really long-term outcomes. unbiased observers have raised several questions about the Laparoscopic Band as outlined below:

• Weight loss results & maintenance - early studies from Europe reported weight loss results that were less substantial than the Gastric Bypass. However, more recent studies from Australia (especially from Dr. Paul O'Brien and Dr. George Fielding) have put out reliable-appearing results in which weight loss after Laparoscopic Band is essentially equivalent to GBP. Comparative studies done between GBP and Laparoscopic Band by surgeons in the uS have shown somewhat less weight loss with the Laparoscopic Band.  The course of weight over many years after Laparoscopic Band points in the direction of long term maintenance of weight, but the actual long term results do not yet exist.
• Band erosion - all surgeons who perform the Laparoscopic Band have found erosion of the Band into the patient's stomach in a small percentage of cases. It appears that this event (which requires removal of the Band) occurs most frequently in the first year or so after surgery, but can occur at any time after Band placement.  Almost surprisingly, erosion usually does not create serious illness. Even though it is not likely to be an emergency, erosion of the Band does always require surgical removal of the Band.
• Esophageal function - some patients have experienced failure of normal esophageal peristalsis (swallowing function) after Laparoscopic Band. If this occurs, it causes painful swallowing, reflux, or regurgitation. Band deflation or removal is required. More recent studies suggest that the occurrence of esophageal failure arises from tightening the Band too aggressively, and that this complication can be almost completely avoided.
• Silastic reaction - it is possible that the material of the Band could create some type of body immune reaction that stimulates a separate disease process such as arthritis or Systemic Lupus Erythematosis (SLE). However the Band is made of a silicone elastomer which is completely non-reactive to the body tissues, as far as it has been possible to determine. The same type of material has been in use in a number of implanted medical devices over time, and no problems with tissue reaction have been demonstrated. Here again, the early data is reassuring but no true long-term information exists.

Risks specific to Laparoscopic Band

• Band erosion - the Band can erode through the wall of the stomach. This results in loss of restriction to eating, or Band infection caused by leakage of stomach juices onto the Band.   Such erosion rarely results in a sudden life-threatening situation for the patient.   Erosion of the Band requires removal of the Band, with plans for a later conversion to a different weight loss procedure.
• Band slippage or shifting - the Band must remain in the correct position on the upper stomach in order to function properly. If it slips out of place or twists, it is likely to cause obstruction of the stomach, requiring fairly urgent re-operation to reposition the Band.
• Swallowing problems - as mentioned above, the function of the Band as a partial blockage against outflow from the stomach pouch may cause the esophagus (which normally pushes food down in a very coordinated way) to become fatigued or damaged and to fail its normal swallowing function. The rate of occurrence of this problem varies widely among published reports, with the more recent studies being more reassuring.
• Hardware breakage - the Band, the port, and the connection tubing are designed to last for life. In fact, the Band itself is almost never reported to break or leak. However, the tubing and the port definitely can become twisted, kinked, or broken. Such events require re-operations (usually minor) for repair or repositioning of the problem spot.
• Injury to stomach or other nearby organs during surgery - even in capable hands, the maneuvers involved in placing the Band may sometimes create injury to the stomach, esophagus, spleen, liver, or to the tissues involved in placement of the trocars. Sometimes such injuries can be addressed at the time of surgery and the Band can still be placed. Sometimes the nature of the injury means it is most reasonable to abandon the operation.

Frequently Asked Questions about the Laparoscopic Adjustable Gastric Banding 

Is weight loss surgery covered by insurance?
Will I be sick a lot after the operation?
How long will it take to recover after surgery?
How much weight will I lose?
How do the weight-loss results with the gastric banding system compare to those with the gastric bypass?
Does the gastric banding system require frequent office visits after surgery?
Does the gastric banding system limit any physical activity?
How is the band adjusted?
Do I have to be careful with the access port just underneath my skin?
Can the band be removed?
Will I need plastic surgery for the surplus skin when I have lost a lot of weight?
Is it true that the gastric banding system seems "tighter" in the morning?
Will I feel hungry or deprived with the gastric banding system?
What will happen if I become ill?
What about pregnancy?
Will I need to take vitamin supplements?
What about other medication?
What if I go out to eat?
What about alcohol?
Can I eat anything in moderation?
Will I suffer from constipation?



Q: Is weight loss surgery covered by insurance?
A: Some policies will outright exclude weight loss surgeries. Others may have certain parameters around which bariatric procedures they cover and how much of the costs they cover. To determine if your insurance policy covers obesity, weight loss or bariatric surgery, refer to the insurance policy package plan offered by your employer.

Q: Will I be sick a lot after the operation?
A: The gastric banding system limits food intake. If you feel nauseated or sick on a regular basis, it may mean that you are not chewing your food well or that you are not following the diet rules properly. However, it could also mean that there is a problem with the placement of the band so you should contact us if this problem persists. Vomiting should be avoided as much as possible. It can cause the small stomach pouch to stretch. It can also lead to slippage of part of the stomach through the band, which would reduce the success of the operation. In some cases, it would also require another operation.

Q: How long will it take to recover after surgery?
A: If the gastric banding system is performed laparoscopically, patients typically spend less than 24 hours in the hospital. It takes most patients about a week to return to work and a month to six weeks to resume exercising. In the case of open surgery or if there are complications, recovery may take longer.

Q: How much weight will I lose?
A: Weight-loss results vary from patient to patient, and the amount of weight you may lose depends on several things. The band needs to be in the right position, and you need to be committed to your new lifestyle and eating habits. Obesity surgery is not a miracle cure, and the pounds won't come off by themselves. It is very important to set achievable weight-loss goals from the beginning. A weight loss of 2 to 3 pounds a week in the first year after the operation is possible, but one pound a week is more likely. Twelve to eighteen months after the operation, weekly weight loss is usually less. Remember that you should lose weight gradually. Losing weight too fast creates a health risk and can lead to a number of problems. Your main goal is to have weight loss that prevents, improves, or resolves health problems connected with severe obesity.

Q: How do the weight-loss results with the gastric banding system compare to those with the gastric bypass?
A: You should focus on long-term weight loss and remember that it is important to lose weight gradually while reducing obesity-related risks and improving your health.

Q: Does the gastric banding system require frequent office visits after surgery?
A: Check-ups are a normal and very important part of the gastric band follow-up.

Q: Does the gastric band limit any physical activity?
A: No, the gastric band does not affect or hamper physical activity including aerobics, stretching and strenuous exercise.

Q: How is the band adjusted?
A: Adjustments are often carried out in the X-ray department. They are done there so the access port can be clearly seen. When X-rays are used, your reproductive organs should be shielded. Sometimes adjustments can be done in an outpatient clinic or office. Local anesthesia may or may not be needed. A fine needle is passed through the skin into the access port to add or subtract saline. This process most often takes only a few minutes. Most patients say it is nearly painless.

Q: Do I have to be careful with the access port just underneath my skin?
A: There are no restrictions based on the access port. It is placed under the skin in the abdominal wall, and once the incisions have healed it should not cause discomfort or limit your movements or any physical exercise. The only sensation you may have from the port is when you go in for adjustments. If you feel persistent discomfort in the port area, talk to your doctor as soon as possible.

Q: Can the band be removed?
A: Although the gastric band is not meant to be removed, it can be. In some cases this can be done laparoscopically. The stomach generally returns to its original shape once the band is removed. After the removal, though, you may soon go back up to your original weight or even gain more.

Q: Will I need plastic surgery for the surplus skin when I have lost a lot of weight?
A: That is not always the case. As a rule, plastic surgery will not be considered for at least a year or two after the operation. Sometimes the skin will mold itself around the new body tissue. You should give the skin the time it needs to adjust before you decide to have more surgery.

Q: Is it true that the gastric band seems "tighter" in the morning?
A: This is a fairly common feeling, especially for people with bands that are tight or just after an adjustment. During the day the water content in the body changes and this may cause the band to feel "tighter" some of the time. Some women have also noticed that the band feels tighter during menstruation.

Q: Will I feel hungry or deprived with the gastric band?
A: The band makes you eat less and feel full in two ways - by reducing the capacity of your stomach and increasing the time it takes food to get through the digestive system. After a small meal, the amount of which varies from person to person, you should feel full. If you follow the nutrition guidelines when you choose your food and then chew it well, you should not feel hungry or deprived. Remember that the gastric band is a tool to help you change your eating habits.

Q: What will happen if I become ill?
A: One of the major advantages of the gastric banding system is that it can be adjusted. If your illness requires you to eat more, the band can be loosened by removing saline from it. When you have recovered from your illness and want to lose weight again, the band can be tightened by increasing the amount of saline. If the band cannot be loosened enough, it may have to be removed.

Q: What about pregnancy?
A: Becoming pregnant can be easier as you lose weight. Your menstrual cycle may become more regular. If you need to eat more while you are pregnant, the band can be loosened. After the pregnancy, the band may be made tighter again, and you can resume losing weight.

Q: Will I need to take vitamin supplements?
A: You may. It's possible you may not get enough vitamins from three small meals a day. At your regular check-ups, your specialist will evaluate whether you are getting enough vitamin B12, folic acid, and iron.

Q: What about other medication?
A: You should be able to take prescribed medication. You may need to use capsules, break big tablets in half or dissolve them in water so they do not get stuck in the stoma and make you sick. You should always ask the doctor who prescribes the drugs about this.

Q: What if I go out to eat?
A: Order only a small amount of food, such as an appetizer. Eat slowly. Finish at the same time as your table companions. You might want to let your host or hostess know in advance that you cannot eat very much.

Q: What about alcohol?
A: Alcohol has a high number of calories. It also breaks down vitamins. An occasional glass of wine or other alcoholic beverage, though, is not considered harmful to weight loss' 1

Q: Can I eat anything in moderation?
A: After your stomach has healed, you may eat most foods that don't cause you discomfort. However, because you can only eat a little it is important to include foods full of important vitamins and nutrients such as those advised by your surgeon and/or dietitian. If you eat foods that contain lots of sugar and fat or drink liquids full of "empty" calories, such as milkshakes, the effect of the band may be greatly reduced or cancelled.

Q: Will I suffer from constipation?
A: There may be some reduction in the volume of your stools, which is normal after a decrease in food intake because you eat less fiber. This should not cause you severe problems. If difficulties do arise, talk to your doctor as soon as possible.

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LAP-BAND DIETARY INSTRUCTIONS POST HOSPITAL DISCHARGE

Amount of food — The surgery reduces the size of the stomach which limits the amount of food consumed to about 1 to 2 ounces (2 to 4 tablespoons). The diameter of this new stomach pouch's exit is also small which delays emptying. Overeating results in distressing pain and/or vomiting.
Frequency and duration of meals — Because volume is limited and stomach emptying is delayed, it is important to eat and drink slowly — patients start with an ounce of food (1 tablespoonful) over about 10 to 15 minutes. Eventually, each meal should take no less than 20 to 30 minutes. In the long run, eating about 6 small "meals" allows for a more nutritionally balanced diet.
Food texture — Initially liquid meals are recommended until the stomach heals. The diet is progressed to puree foods to avoid blocking the small opening. Texture is advanced according to how well foods can be chewed. Taking small bites and chewing foods to a pureed consistency is essential.
Liquids — Only small amounts of liquids should be consumed with meals. This prevents fullness and allows necessary foods to be eaten. However, liquids are crucial to prevent dehydration. They should be sipped between meals.
Nutritious foods — Because the quantity of food eaten is reduced, it is important to select food with the best nutritional value. This is not only important to ensure healing after surgery, but also to ensure that weight loss occurs and is maintained in the long run. The psychological urge to eat will test the capacity of the gastric pouch with increased amounts and varieties of foods. It can be stretched and the purpose of the surgery can be defeated. Food intolerances vary from individual to individual. Vitamin, mineral and other nutritional supplements may also be indicated. It is important to work with a dietitian to ensure that "nutrient rich and calorie poor" foods are eaten.
Follow-up after surgery is essential to monitor weight loss, for blood tests to assess hydration, presence of specific vitamin, mineral, or other nutrient deficiencies, and psychological adaptation to lost weight and lifestyle changes. With time, a gradual increase in types and amounts of foods may be eaten. Within 1 year, most people stop losing weight and attention is directed to diet and lifestyle changes that maintain the weight that has been lost and to prevent regain.

 

When you are discharged from the hospital, you must continue to follow very specific instructions for about three weeks.  You will return to your surgeon about one week after your surgery, at which time you will begin specific diet instructions as to what types of food you can eat.  It is important to follow the instructions below:

For 1 week, you should be on a liquid diet.  This includes HMR (Health Management Resource) Shakes and Designer Protein powder.  The shakes can be obtained from the Weight Management Program.  You are also allowed to include the clear liquid diet (juice, broth, strained soups, jello, water).

Directions for shakes:
Mix 1 package of the shake with 1 scoop of the Designer Protein powder and 6-8 oz of water. 

You can also use Protein Revolution which can be obtained from Trader Joe’s as a substitute for the HMR shakes. 

*Try to drink 3-5 shakes per day, sipping on an ounce every 15-30 minutes.

1. At Week 2 and during the first 1 to 3 months after surgery, all solid food should be ground or pureed or chewed to similar consistency.  Chew all food thoroughly to avoid blockages.  Avoid vomiting by chewing your solid foods sufficiently (20-30 times, eating slowly, or not over-eating.)  This can expand and possibly rupture your small pouch.  If vomiting is persistent, return to an all-liquid diet for one or two days before resuming the suggested diet.  Call your surgeon if vomiting persists.  Do not try to induce vomiting to relieve symptoms of bloating or fullness.
2. Stop eating at the first feeling of fullness.  One or two bites more may cause vomiting.  Remember, it is not necessary for you to “clean your plate.”  Eat slowly (20-40 minutes per meal) to avoid dilating the pouch.
3. Do not eat more than 5 small meals a day.
5. Only drink water or other low-calorie liquids.  Citrus juices such as orange or grapefruit have a high acid content and should be avoided.  High calorie liquids can defeat the purpose of the surgery.  Drink at least 4-6 glasses of liquids a day to avoid dehydration and constipation.
6. Drink between meals, not during meals.  Liquids should be taken 30 minutes before and after meals.  Remember there is not enough room in your “new” stomach for foods and liquids at the same time.
7. You should take a multivitamin-mineral supplement.  To avoid vomiting, divide the tablet in half and take them between meals, not on a full stomach, or take a chewable or liquid vitamin-mineral supplement.  Here are some suggestions for vitamins/minerals:

a) Flintstones Complete Chewable Multivitamin/mineral – take 2 tabs
everyday

Other Adult Chewable
or
ultra-Mega Multivitamin

1. If constipation occurs, milk of magnesia, prune juice or natural laxatives may be taken.  You may also take a psyllium fiber supplement.
2. Eventually the pouch will expand to allow 4-5 ounces at a meal.  You should not eat more than 4-5 ounces (1/2 cup) at one meal.

Post Lap Band Soft Diet

Sample Meal Plan

Breakfast

1 oz. protein (ground chicken, turkey, fish, low-fat cheese, or egg)
1 fruit
1 starch

Wait 30 minutes and drink:  4-8 oz skim milk or HMR shake

Lunch

1-2 oz protein (ground chicken, turkey, fish, low-fat cheese, or egg)
1 vegetable

Wait 30 minutes and drink:   4-8 oz skim milk or HMR shake

Dinner

1-2 oz protein (ground chicken, turkey, fish, low-fat cheese, or egg)
1 vegetable
1 starch

Wait 30 minutes and drink:   4-8 oz skim milk or HMR shake

1 Starch =1 slice bread; ½ bagel; ½ cup rice; potato or noodles; ½ cup hot cereal; ¾ cup dry cereal; 4 crackers; ½ cup peas or corn

1 Fruit = 1 small piece of fruit; ½ small banana; ½ cup cut up fruit without sugar; 4 oz. fruit cup packed in its own juice and drained

1 Vegetable = 1 cup plain non-starchy vegetables

The above menu represents the maximum amount of food and you may tolerate various foods in different quantities.  You will not be able to consume the amounts shown right after surgery.  Remember to focus on PROTEIN first.