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Description - Video - After Surgery

Description of Procedure

Adjustable gastric banding, or Lap band surgery, is a form of restrictive weight loss surgery (bariatrics) designed for obesity patients with a body mass index (BMI) of 40 or greater - or between 35 – 40 with those who have comorbidities that are known to improve with weight loss. The gastric band is an inflatable silicone prosthetic device which is placed around the top portion of the stomach via keyhole laparoscopic surgery.

In general, gastric banding is indicated for people for whom all of the following apply:

Body Mass Index above 40, or those who are 100 pounds (45 kg) or more over their estimated ideal weight according to the 1983 Metropolitan Life Insurance Tables or those between 30 to 40 with co-morbidities which may improve with weight loss (high blood pressure, diabetes, sleep apnea, and arthritis).
Age between 18 and 55 years (although there are doctors who will work outside these ages, some as young as 12 ).
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 glandular diseases such as hypothyroidism.
Inflammatory diseases of the gastrointestinal tract such as ulcers, esophagitis 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.
Mentally retarded or emotionally unstable people.

Gastric banding as an alternative to other weight loss surgeries
Lower mortality rate, only 1 in 2000 versus 1 in 200 for Roux-en-Y gastric bypass surgery
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

Video

After Surgery

Correct and sensitive adjustment of the band is imperative to weight loss and the long term success of the procedure. Adjustments (also called "fills") may be performed using X-ray fluoroscope so that the radiologist may assess the placement of the band, the port and the tubing which runs between the port and the band. The patient is given a small cup of a liquid containing a radio opaque fluid similar to barium – clear or white. When swallowed, the fluid is clearly shown on X–ray and is watched as it travels down the esophagus and through the restriction caused by the band. The radiologist is then able to see the level of restriction in the band and to assess if there are potential or developing issues of concern. These may include dilation of the esophagus, an enlarged pouch, prolapsed stomach (when part of the stomach moves into the band where it does not belong), erosion or migration. Reflux type symptoms may indicate too great a restriction and further investigation would be required. In some circumstances fluid would be removed from the band prior to further investigations and re-evaluation. In some cases further surgery may be required (e.g. removal of the band) should gastric erosion or similar be detected.

Some health practitioners adjust the band without the use of X-ray control (fluoroscopy). For example, this is standard practice in the main bariatric surgery clinic in Melbourne, Australia, where AGB placement has been performed for more than ten years. Some UK services, such as Bristol, also do non-fluoroscopic adjustments. In these cases, patients visiting for a regular fill adjustment will typically find they will spend more time talking about the adjustment and their progress than the actual fill itself, which generally will only take about 60 seconds to two minutes.

For some patients this type of fill is not possible, due to issues such as partial rotation of the port, or excess tissue above the port making it difficult to determine its precise location. In these cases, a fluoroscope will generally be used.

No accurate number of adjustments required can be given. However, an average may be estimated to be between three and five fills (where saline/isotonic solution is inserted into the band via the subcutaneous port) for a person to reach the optimal restriction for weight loss. The amount of saline/isotonic solution needed in the band varies from patient to patient. There are a small number of people who find they do not need a fill at all and have sufficient restriction immediately following surgery. Others may need significant adjustments to the maximum the band is able to hold. Bands come in several diameters and sizes and can hold a total of between 4 cc (ml) to 12 cc (ml) of fill fluid depending on the design. Band preference is usually determined by personal preference of the surgeon who places the band together with what he is either able to use (e.g., specific bands approved in country of surgery) or what s/he believes to be the most appropriate. In Europe e.g. it is possible for the surgeon to use many designs. The size of the band used is determined by the surgeon during surgery based on the size and thickness of the patient's stomach.

It is more common practice for the band not to be filled at surgery – although some surgeons chose to place a small amount in the band at the time of placement. The stomach tends to swell following surgery and it is possible that too great a restriction would be achieved if filled at the time of surgery. Clearly, this is undesirable.

The patient may be prescribed a liquid only diet, followed by mushy foods and then solids. This is prescribed for a varied length of time and each surgeon and manufacturer varies. Some may find that that before their first fill that they are still able to eat fairly large portions. This is not surprising since before the fill there is little or no restriction and is why a proper post-op diet and a good after-care plan is essential to success. Many health practitioners make the first adjustment between 6 – 8 weeks post operatively to allow the stomach time to heal. After that fills are performed as needed. Some practitioners may be more aggressive than others, but most appear to require a 2-4 week wait between fills. It is very important to discuss post-surgical care and diet plans with your weight loss team if you are considering this surgery. Recommendations can vary dramatically from team to team and it is important to find a weight loss team with a good post-surgical plan. Some teams offer support groups, but unfortunately many of them mix RNY patients with gastric banding patients. Some gastric band patients have criticized this approach because while many of the underlying issues related to obesity are the same, the needs and challenges of the two groups are very different, as are their early rates of weight loss. Some gastric band recipients feel the procedure is a failure when they see that RNY patients generally lose weight faster.

Effectiveness
The average gastric banding patient loses 500 grams to a kilogram (1-2 pounds) per week consistently, but heavier patients often lose faster in the beginning.[citation needed] This comes to roughly 50 to 100 pounds the first year for most band patients. It is important to keep in mind that while they drop the weight faster in the beginning, most of the RNY patients will have the same percentage of excess weight loss and comparable abilities to keep it off after only a couple of years. Gastric banding patients may have to work a little harder in the first couple of years, but the procedure tends to encourage better eating habits which, in turn, helps in producing long term weight stability.

A systematic review concluded "LAGB has been shown to produce a significant loss of excess weight while maintaining low rates of short-term complications and reducing obesity-related comorbidities. LAGB may not result in the most weight loss but it may be an option for bariatric patients who prefer or who are better suited to undergo less invasive and reversible surgery with lower perioperative complication rates. One caution with LAGB is the uncertainty about whether the low complication rate extends past three years, given a possibility of increased band-related complications (e.g., erosion, slippage) requiring re-operation".[3]

Other positive effects of gastric banding

Effects on Depression
Recent studies show that the gastric band can have a positive effect on depressive patients. Two groups of 600 overweight patients, each > 40kg/m, were closely watched for 5 years. Both groups had about 29% depressive patients. After 6 months both groups of patients were less depressed. After 5 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.

Quality of Sleep
About 38% of gravely overweight women and 48% of overweight men are suffering from severe sleep apnea. An Australian study [5] is now trying to show that a gastric band operation can have a positive effect on the sleep apnea. Since weight loss generally has a good effect on sleep apnea, and the gastric band usually leads to weight loss, chances are that the gastric band has a positive effect on sleep apnea,[citation needed] reducing the tiredness during the day and therefore increasing the work-performance of the patient.

Keep in mind, the amount of time it takes to return to normal activities is different for every patient. Recovery time is often faster for patients who are young and in good physical condition. Maintaining a healthy attitude, a well-balanced diet, and getting plenty of rest can also shorten recovery time. Recovery is much slower for people who smoke and are overweight or out of shape.

Some people experience temporary bouts of moodiness or emotional let down after surgery. Do not fear that this is a setback or will lengthen your recovery time. Emotional changes are normal and may be due to the body working hard to heal itself. They may also be due to unrealistic expectations about how long it takes to feel "normal" again. Keeping a positive attitude is important during this time. Focus on making small improvements each day with an eye toward the continued progress you will make in the future.