Gastric Band

Laparoscopic Gastric Banding

If you are seriously overweight and have tried diets, exercise programmes, tablets or medicines and they haven't helped you lose and maintain a healthy weight, an option may be an operation to artificially reduce the amount your stomach can hold and decrease your appetite.

Laparoscopic Gastric Banding For Obesity

Poor quality of life, low self esteem and significant health risks are linked to excess body weight (early death, diabetes, hypertension, joint pains, gallstones, etc.). Unsuccessful attempts to lose weight by dieting are the main reasons why patients consider surgical interventions to control their obesity. Laparoscopic gastric banding is the simplest and least invasive procedure available to help patients to lose significant weight and improve their health and reduce co-morbidities.

There are a number of bands available (The Swedish and the Bioenterics Lap Band are the most common). I routinely use only the Lap Band because of its durability and low erosion rate. The Swedish Adjustable Gastric Band (SAGB) was developed in Sweden back in 1985, and the Lap band in the USA in 1992. Almost all operations are now performed using keyhole surgery (laparoscopically). Other surgical methods are still in use for the treatment of morbid obesity, but these tend to include some form of stapling or cutting of the stomach and/or the intestines. This is not the case with adjustable gastric banding. Other surgical methods also carry much higher operating risks, more long-term complications, and make any revision back to the original structure of the stomach and intestines more difficult.

Unlike other surgical procedures adjustable bands can be adjusted to your requirements at any time after the operation. This means that weight loss can be regulated according to your needs and your optimal well-being.

The band is fitted around the uppermost part of your stomach about 2cm past the point where the oesophagus joins the stomach forming what is called a virtual pouch. The diameter of the gastric band can be adjusted to your optimal weight loss requirements and well-being by injecting or removing saline via an injection port placed fixed to the muscle layer. The stomach is not modified surgically so it is possible to revert back to the normal anatomy at any time by laparoscopically removing the band.

How does gastric banding work?

The mechanism of action of the gastric band is the subject of ongoing research. It has become plain that the device does not work simply by restricting the amount of food that patients can consume. Research at the Monash Centre indicates that as food is swallowed it is squeezed through the band by the oesophagus. The stretching of the pouch and oesophagus stimulates the vagal nerves and this gives a feeling of fullness and satiety. To make the band work in an optimal way patients should eat small meals at regular intervals. They should have small mouthfuls of food, chew thoroughly and allow 30 seconds after swallowing to allow the food bolus to pass through the band before starting the next mouthful. To keep eating before the pouch has emptied causes overfilling of the pouch and oesophagus leading to excessive vomiting and regurgitation. Long term this causes pouch enlargement and oesophageal dilatation as these areas are being constantly stretched. These problems can lead to the band having to be repositioned or deflated for a long period. The golden rules as regarding correct eating techniques are as follows:-

• Eat small saucer sized meals regularly.
• Make sure the food is nutritious and of soft moist consistency.
• Eat small mouthfuls and chew thoroughly.
• Allow 30 seconds after swallowing before starting the next mouthful to allow the pouch to empty.
• Stop eating if you are feeling full.

Gastric banding should induce an early feeling of satiety and reduce meal volumes , thereby decreasing food intake. You should eat less but you will need to change your basic behaviour pattern towards food selecting soft moist low fat foods and learning to eat slowly and to chew thoroughly. The band should induce sustainable weight loss, which in turn leads to a healthier lifestyle with less risk of obesity-related secondary diseases. If, however, the gastric band is removed you will most likely quickly regain your lost weight.

Immediately after surgery you will be put on a diet supervised by my dietitian. For the first two weeks you will only be allowed liquid food. For a further two weeks you will be restricted to pureed food. This is to allow the sutures securing the band, to heal strongly and prevent slippage of the band down the stomach. During the healing process, tissue adhesions develop and help fix the band in the right place. Patients who eat solid food too soon after their operation run the risk of dislocating the band, thus developing an enlargement of the new upper gastric pouch. This leads to obstruction and vomiting and, in some cases, the need to re-operate. Patients then commence their soft high protein high fibre diet under the supervision of my dietitian. (See Laparoscopic Gastric Banding - post-operative advice).

At 6 weeks after the surgery, the band may be tightened to increase the feeling of restriction if you are not losing weight. If you are losing at the rate of 0.5kg or more then the band should not be tightened as it is doing what we want. If you are not losing and are eating too much then the band is progressively tightened until a saucer sized meal provides fullness.

My dietitian will provide you with a diet plan for this period. Some foods will be difficult to eat (fresh white bread and red meat) and most will need to be carefully chewed. High kilojoule liquid foods and drinks ie. chocolate, icecream and Coca Cola, must be avoided as they pass too easily through the band without causing satiety. This can stop weight loss. The volume of food able to be eaten is dependent on how tightly the band sits around the stomach and is, therefore, directly related to the amount of weight that you are aiming to lose. The looser the better as you can enjoy a wider variety of foods and will have less side effects and complications if the band is not too tight. This operation is the first step in a major life adjustment. Aim for slow steady weight reduction over 12 to 18 months. During the convalescence period, the wounds will heal and you will have to adjust to a new eating behaviour. You should understand that surgery is not a quick fix. It is always associated with at least some degree of risk and depends on the patient using the band correctly. There is no guarantee of a successful outcome for each and every individual as weight loss is dependant on patient compliance. It is therefore important that you read and understand the complication risks listed below.

Preoperative Check-up

Preoperatively you will be assessed to see that you are fit for the operation and that you do not suffer from any of the following:

• Alcohol or drug abuse
• Endocrine related obesity, i.e. thyroid malfunction
• Severe psychological problems or mental illness

Anatomy

The anatomy of each individual varies greatly. For this reason, technical difficulties during surgery may mean that it will not always be possible to place the band in its optimal position. Large fat infiltrated liver can make positioning of the band difficult and this is why we advise Optifast for 2 weeks prior to surgery as it de-fats the liver. A large hiatus hernia can interfere with the band placement and may require repair. Small hernias may also require tightening of the hiatus to minimise tendency to reflux pot-operatively.

Dietary Instructions

The banding operation is the first step towards a major readjustment in the patient’s lifestyle. During the period of convalescence the wounds will heal and the patient will have to learn a new pattern of behaviour. This can take time as learning how to use the band can involve a degree of experimentation with various foods and eating patterns to determine which diets suit each individual patient best. My dietitian will help you to make the right choices. Patients will have to learn the importance of chewing their food.

They must also understand the importance of modifying their attitude towards physical exercise, and introduce this into their lifestyle. I am working with Mr Adrian Cuda a fitness and lifestyle consultant to develop optimal exercise programs and group exercise sessions to maximise weight loss and improve physical fitness. His website is www.thebandnu.com.au. Alternatively patients should monitor how many steps they walk in a day with a pedometer and build this up to 10,000 steps per day.

During the first month following the operation, the patient’s diet should only consist of liquid and pureed food. The reason for this is that the body needs time to heal, operative swelling to subside and to develop the adhesions around the band These which will maintain it in its correct position. Patients who eat solid food too soon run the risk of dislocating the band, thereby developing an enlarged upper gastric pouch.

Fluid intake commences on the evening of the day of the operation. Patients commence carefully sipping clear fluids as soon as they feel any nausea has passed off. The remainder of the fluid requirement will be given intravenously. The oral intake of fluid can then be rapidly increased over the next few hours. If the patient is able to drink adequate and is reasonably comfortable and mobile, they will be discharged the day after surgery.

From the second or third day onwards, liquid and food requirement should be fulfilled as follows:

Period 1: Liquid diet for 2 weeks

On average, 1.5 litres of fluid per day should be taken in small amounts sipping carefully. The type of fluid should be varied and can consist of low-fat milk, drinking yoghurt thin gruel, tea or coffee, fruit or vegetable juices, and warm soup or broth. Anything that can go up through a straw is suitable. A dietary supplement drink should also be included to maintain a balanced diet. It is important to spread the fluid intake over the whole day, absorbing small amounts at a time.

Period 2. Pureed food for 2 weeks

The purée should be taken in small portions 50-60 mls at a time. Eat a small helping when hungry. Soup and dietary supplements should still be included in the daily diet. Most food stores sell pots of baby food suitable for infants aged 5-6 months. These pots are the most suitable option at this stage, as the food has the correct consistency. Eat slowly using a tea spoon.

Patients should not drink during their meals, but in-between. Meals can be adjusted to the condition of the patient, but it is important that the recommended amounts are observed as closely as possible.

The total amount of liquid intake must be at least 1500ml per day. Liquid should be absorbed at regular intervals, 100-200ml at a time. The type of liquid should be varied and include tea or coffee, milk or yoghurt, fruit or vegetable juices. The total intake of puréed food should be around 500g per day. The puréed food should contain meat or fish, and be divided into meals no bigger than 100-150g at a time. Food must always be eaten slowly, in small mouthfuls.

Period 3: Small portions of moist food for 2 weeks

Food of soft moist consistency, can now be introduced into the diet. The portions should, however, always be kept small, and drinking should still be restricted to the periods between meals. It is very important to eat slowly and to chew the food thoroughly. The patient must make sure to drink only the low fat variants of milk or yoghurt and low kilojoule diet drinks. Patients must trial solid food before the degree of restriction of the band can be assessed. If they are eating less and losing weight then the band is providing adequate restriction and should not be tightened as this will not accelerate weight loss. If patient do not continue to lose weight and feel hungry this is the point at which the band may be tightened.

The total daily amount of liquid intake should be at least 1500ml and the total amount of solid food intake around 500g. The solid food may now be taken at normal eating hours. It is, however, important that enough time is allowed to eat slowly. 3 regular saucer sized meals a day should be eaten. Patients may have small nutritious snacks between meals if they are hungry. Eating when hungry keeps hunger under control. Eat small, regularly and in a healthy fashion. Do not miss meals as this will lead to voracious eating and increased vomiting and reflux.

Period 4: Patients can start to make up their own diets

It is still important, however, that they eat little and often, and chew the food thoroughly. Drinking is allowed only between meals and only in sugar-free alternatives. Menus should be based on boiled or mashed vegetables. Fish or low fat white meat must be steamed or stewed rather than fried. Other products should also be of low fat content (light milk, light cheese with a maximum 17% fat content, light ice-cream, etc.). My dietitian will help you with food choices.

Food Restrictions

Certain foods, i.e. white bread and red meat, are not easily tolerated and should be avoided unless they can be broken down into easily digestible alternatives. These are foods that generally get stuck in the opening of the stomach and are therefore likely to cause obstruction, and thereby vomiting and fluid depletion.

The majority of patients will also find it difficult, if not impossible, to eat whole chunks of meat, although ground beef is generally tolerated if well chewed. It is therefore, advisable to abstain from eating meat in the beginning and only introduce this progressively into the diet. Much depends on how much fluid is injected into the band's balloon as this affects the size of the aperture between the upper and lower part of the stomach. A small opening will allow greater weight loss, but will also require from patients that they be more careful about what they eat. With the balloon totally empty, the patient should be able to eat almost normally.

General Advice and Possible Minor Side-Effects

Vomiting or Acid Reflux

Patients occasionally vomit or feel pain after food intake. This can be caused either by poor eating behaviour ie too large a quantity or not chewing, or by the narrowing of the band following the injection of fluid into the balloon. By eating slowly and calmly. Chew thoroughly and eat slowly .You will learn to listen to the signals from your stomach. Regular vomiting or reflux is definitely a warning sign. In such cases, the amount of liquid in your band may need to be reduced.

Repeated vomiting can lead to serious dehydration and patients should contact their surgeon immediately if they have not kept down fluids in reasonable amounts for 48 hrs.

Vitamins

Vitamin supplements are advisable. A liquid vitamin mixture or chewable tablet containing multivitamins, in particular the vitamin B complex and iron is recommended daily following surgery. Additional iron is important especially in young women because of lack of red meat in the banding diet. It is advisable to have a 6 monthly blood test to check blood count, iron Vitamin B12 thiamine and folic acid levels. Your family doctor can arrange these.

Pregnancy

The period between surgery and weight stabilisation is considered as a period of starvation. It is not advisable to become pregnant during starvation, despite the fact that the foetus has priority over the mother with regard to food. Should you nevertheless get pregnant while losing weight it is advisable to reduce the volume of fluid in the balloon. Once your weight has stabilised, pregnancy is not a problem and adjustment may not be necessary.

Medication

Tablets may need to be broken down into small pieces or crushed before they are taken. It is common that medication for conditions such as hypertension, diabetes or asthma, may need to be altered (reduced) after this operation. Patients should consult their family doctors about this matter.

Constipation

Many patients feel constipated after surgery. This is mainly due to the fact that the reduced food intake leads to less faeces and thus fewer bowel movements. If laxatives become necessary, it is advisable to abstain from so-called bulking agents and instead use liquid laxatives, such as lactulose.

Doctor Appointments

After surgery you must undergo regular check-ups at my office. Initially, these checkups will coincide with band adjustments and will be carried out frequently, but soon visits will become less frequent. The band will gradually be filled via the injection port during the first 18 months following surgery. During this period, your weight loss and level of well-being will be monitored. Once your weight has stabilized, checkups will be necessary on an annual basis. 6 monthly blood count, iron levels and assays of Vit B12 and Folic Acid are advisable. These can be arranged with your family doctor with a copy of the results sent to my office for checking.

Physical Activity

It will be important to alter not only your eating habits, but also your level of physical activity. If you are too sedentary it is difficult to lose weight. Patients are generally recommended to start exercising as soon as they leave hospital. As weight loss is achieved, physical activities will gradually become easier. Aim to walk immediately after discharge and work towards walking 10,000 steps / day monitoring progress with a pedometer or doing a similar amount of aerobic exercise. This helps burn up some kilojoules and increases fitness and wellbeing.

What constitutes reasonable weight loss with a gastric band?

Average weight loss is 62% of excess body weight at 2 years post-operative. There can be some weight regain with weight loss settling at an average of 53% of excess body weight. Patients can achieve weight reduction to ideal body weight if they rigidly obey all their advice but most cannot adhere rigidly to their diet and exercise programs. 53% reduction of excess body weight is enough to produce major improvements in health and co-morbidities which is the aim of surgery.

Main Complications

The laparoscopic banding procedure operation is not without complications, but these occur on a small scale and have a much lower risk profile compared to other methods currently used in obesity surgery.

Operative Complications

Please note that these figures are as at May 2008 and may not be entirely accurate, as they can change regularly.

I Am Pleased To Say That There Have Been No Deaths In My Series Of 1300 Adjustable Laparoscopic Band Insertions

The incidence of serious operative complications is low.

Complications occurring at the time of band placement in my series are:

• Puncturing or tearing the gastric wall at surgery causing leakage and infection requiring repair and band removal (3 cases ( 0.23%) in my series). This is a serious and life threatening complication.
• Tearing the spleen causing haemorrhage and requiring removal of the spleen (0 cases).
• Puncturing another organ with one of the laparoscopic instrument when they are first inserted into the abdomen (3 cases (0.23%) requiring laparoscopic repair).
• Damaging the band by needle prick (none known).
• Pulmonary embolism (9 cases (0.69%). This can be life threatening.
• Pneumonia (8 cases).
• Obstruction by the band requiring revision (2 cases (0.15%) ).
• Infection of the device requiring it to be removed (0 cases).
• Haemorrhage from an abnormal vein in the hiatus requiring urgent open surgery to stop the bleeding. (1 case (0.8%) ) Haemorrhage can be life threatening

Patients must mobilize and use their Triflow spirometers as soon as possible after surgery to minimize the incidence of pulmonary embolism and chest infection.

Long term problems may arise that require re-operation. Approximately10% of patients will require another operative procedure as time passes. The principal long term postoperative problems that mandate re-operation are as follows:

• Migration of the Band into the Stomach (2% in my series of Lap Bands 11% With Swedish bands)

  Since the improvement of the operating technique, migration remains the most serious complication in the banding operation. The rate of migrations has been reported to be between 0.6- 15%, and appears to be directly correlated to the amount of fluid injected into the balloon. If too much fluid is injected, the band will exert considerable pressure onto the stomach wall, thus increasing the risk of migration. Eating large food volumes also applies pressure to the band and may increase the risk of erosion. Small frequent helpings will help to avoid this complication. NSAIDS ie. Aspirin, Neurofen and Indocid can produce ulceration and mucosal damage and promote erosion. Use paracetamol only for analgesia.

  The band should therefore, never be filled with more than the recommended volume (SAGB -9 ml of fluid, Lap band -4ml). The lower the amount of fluid in the band, consistent with slow weight reduction, the better.

  Migration is also possibly caused by subclinical infection. A subclinical infection may occur as a result of contamination of the band, via injections into the port. Both the port and the tube are covered by a fibrotic shield and it is thought that contamination may be transported down to the band from the port area. It is very important to swab the skin with Betadine before injecting fluid into the band.

  Injections into the port are generally performed during the first 18 months following surgery and migration of the band tends to occur within the first two years following surgery. The rate of clinical infections also increases in those patients with a migrating band.

  If migration of the band does occur, it is often possible to perform repeated endoscopic examinations until most of the band has migrated into the stomach., It may be able to be removed by an endoscopic technique, making only one incision to remove the access port. As a rule no acute situation or infection occurs and this procedure simplifies re-operation. The band can then often be replaced after 3-6 months if the patient so desires. If laparoscopic removal is necessary then the hole in the stomach has to be closed by suturing and there is a risk of leakage. The whole band can migrate into the stomach and down into the small bowel causing obstruction. The band is still attached to the tube and cannot pass out through the bowel. This is a dangerous situation and is why eroding or migrating bands should be removed.

• Slippage of the Band & Pouch dilatation requiring repositioning of the band. (4.75% in my series)

  Research has shown that the higher the placement of the band, the lower the risk of slippage. This technique is known as the pars flaccida approach as the band passes through the fatty pad on the back wall of the stomach and is fixed in place by the body tissues. In the technique of passing the band through the lesser sac, the risk of slippage is increased. Careful tunnel formation with 4-5 sutures over the front surface of the band, significantly decreases this problem.

  The risk of slippage is also increased by:

  • Not emptying the balloon during surgery
  • Filling the band too early
  • Introducing solids too soon into the diet
  • Eating excessive quantities and overfilling the small pouch
  • Having the band too tight and not allowing food to pass steadily through the opening into the lower pouch

  The problem of slippage is, however, small. Slippage causes the pouch to enlarge and the stoma to drain poorly. This results in severe reflux and vomiting. The band has to be opened by a laparoscopic technique and the stomach pulled back down through it or the band can be removed ands placed at a higher level. It is then resutured into place. This can be a complex procedure although it sounds simple. It carries a higher risk of perforating the stomach as the plane behind the stomach is adherent to the diaphragm with dense scar tissue making it difficult to open this plane to insert the band. Another option is to remove the band and replace it at a later stage.

• Leakage from the Lap Band (0% in my series )

  There have been no cases of leakage from the Lap Band. Leakage can result from the silicone tube being punctured close to the access port and also occur following poor treatment of the balloon during surgery i.e. grasping with an instrument or pricking with a needle. Leakage can, however, also occur spontaneously at any time after surgery due to failure of the device.

  Although only a few cases of leakage from the balloon itself have been reported to date, earlier series did report rates varying between 1-2%. The types of leakage reported can be divided into two distinct groups.

  The first is where the balloon has been visibly broken, sometimes as a result of a poor surgical technique. The leakage may remain unnoticed for a considerable amount of time after surgery.

  The second involves very slow leakage, and results in the balloon having to be filled repeatedly. This can occur many years after surgery and is believed to be caused by some kind of wearing of the band within the body. This has occured with the Swedish band due to folding of the balloon membrane and cracking at the apex of the folds.It has occurred in 2% of Swedish bands.

  The lifespan of the Lap Band is uncertain but many have been in place since 1994 without failing so they appear to be durable and long lasting but may not be durable enough to last a lifetime. We cannot say what the lifespan of the band is at this time.

• Oesophagitis and Reflux (13.5% in my series)

  The larger the pouch, the greater the problem of oesophagitis. Patients will occasionally need to be prescribed i.e. Losec (Astra Pharmaceuticals) and have some deflation of the band. Although oesophagitis is a relatively widespread problem, it is not considered to be serious as long as it is treated. It can be due to the band being too tight or due to mal-position of the band. If the patient ignores the symptoms and the oesophagus remains ulcerated, as it can in severe cases, then the oesophagus can be damaged. It helps to eat the evening meal early and to eat the smallest and most liquid meal possible. The pouch should be allowed three hours to empty before lying down, as most reflux occurs at night.

• Vomiting (Common)

  Some patients have trouble adapting to their new situation; they repeatedly eat and then vomit. They do not measure the size of their meal, do not choose soft easily chewed food and do not eat slowly. Paradoxically, most of these patients still lose weight and are very pleased with the operation. If a patient continues to vomit and proceeds to lose weight rapidly, fluid should be immediately removed from the balloon until the patient is again comfortable. If the patient vomits and does not lose weight, other options need to be considered. If the pouch is too small and has not yet reached its optimal size, vomiting may result from too rapid tightening of the stoma. In such a case, enough liquid should be removed from the balloon in order to stabilize the patient’s condition. After a period of three months it should be possible to re-tighten the band.

• Infection of the Port (1 case in my series)

  Port infection can be kept to a minimum by carefully complying with the disinfection instructions. It may also mean that the band is migrating into the stomach. A port that becomes infected some years after surgery, should be investigated by endoscopy.

  If an infection does occur, the port must be removed. The silicone tube should then be plugged and sutured down onto the fascia. The infection may then be treated and the port reinserted at a later stage in a different position.

• Foul Smelling Belching (Occasional)

  Bad smelling belching may occur in patients whose pouch is too large, and can be cured by prescribing Flagyl for ten days.

• Ripping of the Tube from the Injection Port, Leakage from or Displacement or Rotation of the Access Port (0.75% in my series)

  It is essential to place the tube in a large loop on top of the left upper abdomen before passing it through the abdominal wall, as extensive movement may otherwise cause the tube to break off close to the port. The access port may tear free from the abdominal muscles causing it to rotate or may drop into the abdominal cavity. It then cannot then be needled and adjusted. The port needs to be repositioned by a minor procedure.

• Oesophageal Dysfunction and Dilatation (5% estimated)

The oesophagus has to be able to push food through the pouch and opening into the lower stomach. That is why it is important that the band is not too tight. Too much resistance may result in the oesophagus dilating and and becoming non-propulsive. This can lead to severe reflux with inhalation of acid. The band should be fully deflated for three months and the oesophagus checked with a barium meal to see if it has returned to normal. If so the band can be gently re-inflated. If it remain dilated the band may have to be removed.

If, having read and understood the above information, you wish to make with an appointment with Dr James Ritchie to discuss going ahead with surgery, please follow this link.