Laparoscopic Adjustable Gastric Banding

Section 1. Laparoscopic Adjustable Gastric Band - Is it right for you? [back to top]

The adjustable band works by inducing satiety
The laparoscopic adjustable gastric band (LapBand™ or RealizeBand™) is a tool that works by suppressing your hunger (it makes you feel satiated). This sensation of fullness is called ’satiety’ and is an extremely important concept for band patients. The goal is for you to not feel hungry, even if you have not eaten for a long period of time. Food becomes less a central part of your life and you start to focus on other more healthy endeavors.

When you eat, you will feel full very soon after you start eating. You will not need to eat much with each meal in order to have satiety and each small meal will provide you with a sense of fullness for a long time until your next meal. A goal of band surgery is that you won't feel hungry before you go to bed at night or when you wake up in the morning.

Important features of the band are adjustability, minimally invasive placement, and reversibility
Adjustability is the primary advantage of band surgery compared to all other current weight loss surgery operations. Satiety is controlled by pressure of the inflatable balloon on the stomach. Increasing the amount of fluid in the band increases the sense of satiety while reducing the amount of fluid decreases satiety.

At surgery, the band is placed without adding fluid, because the goal of surgery is simply placement of a tool that will be used later. Initially the band feels tight around the upper stomach because of the swelling caused by the operation. Most patients initially feel hunger suppression and we want you to remember this feeling of 'satiety' because the adjustment process will attempt to return you to this sensation.

During the month after surgery, this swelling goes away along with the sense of fullness. Hunger then typically returns. It is very important to recover from surgery without dehydration, nausea, or vomiting that may be caused by a band that is too tight because of a fill performed at the time of surgery and this is why the band is not routinely filled until recovery from surgery is complete.

After full recovery, we can start to achieve satiety control again by injecting saline solution by needle through the skin into a port which has been fixed underneath the fat of the abdominal wall (usually 1-3 inches below the skin level).

Adjustable band surgery is performed laparoscopically nearly 100% of the time. While the other types of weight loss surgery are frequently performed this way as well, it is important to also understand that the torque required for the surgeon to access the upper part of your stomach is less than the torque on the abdominal wall needed for laparoscopic gastric bypass or duodenal switch surgery. There is very little damage to the tissues inside the abdomen during band placement and no cutting or stapling of intestines or the stomach.

We have no intention of reversing the procedure. If we did reverse the procedure and took no other steps, we would expect your weight to rise and most patients would return to the original pre-surgery weight. However, there are situations where you may wish to have it reversed, and it is nice to know that this can be achieved relatively easily. Since the laparoscopic adjustable gastric band is placed laparoscopically, it can be removed laparoscopically and as nothing permanent has been done to the stomach, the stomach will return to its normal shape.

Twenty years from now, therefore, if someone invents a new magical cure for obesity, the laparoscopic adjustable gastric band could be removed and the new treatment applied. Absorption of vitamins and minerals is not affected and the pathway that food takes from the mouth to the intestines will remain normal.

Adjustable band placement is the start of a lifetime process; it is not a one-time fix
We expect that you will have excellent results after adjustable band surgery, but this will require a combined effort from you and from us. Your journey of weight loss with adjustable band surgery starts before the band is placed and continues forever after surgery. The two key partners are the surgeon, who is the leader of the surgical team, and you, the patient. Each partner is critical to the success of your surgery and contributes to that success.

The surgeon's primary role is to make sure that the band is placed safely, accurately, and securely. In addition, his role is to make sure that you have timely and open access to band assessment and adjustment appointments and to understand the entire post-operative care of the band patient. Moreover, the surgeon's job is to also make sure that you are aware of your responsibilities, including how much you can eat and drink and how much you should exercise and participate in vigorous daily activity. Finally, but perhaps most important, you must keep in contact with our program keep in contact with us forever. Adjustable band surgery is not a good option for a patient who is not committed to this lifetime partnership.

There are a number of rules of eating and exercise that you will need to follow after surgery. These rules are detailed here (link here to the eating and exercise chapters). In summary, you will be asked to each just 2 or 3 small meals each day with no snacks in between. Each meal should consist of food that must be chewed (i.e. solid food). The food should have good protein content and may include meat, egg dishes, dairy products, beans, lentils and foods with high fiber content like breakfast cereal, vegetables, and fruit. All foods high in fat and simple sugars (i.e. fructose) should be avoided.

You will eat slowly, taking about 30 minutes for each meal, and the volume of food for each meal will be about ½ cup or less. It is nearly impossibly to attain these targets of meal size and frequency without a tool for assisting with appetite suppression. Hunger is an incredibly powerful symptom. The band assists with suppressing hunger and allows for this eating behavior to occur.

All liquid calories (i.e. ice cream, chocolate, slimfast, soups, or anything that spills off a spoon) should be avoided. Calories in the form of liquid will defeat the weight loss objectives of band surgery. Liquids may be consumed, but must be liquids that don't have any significant calories, such as water, mineral water, coffee (without milk or cream), tea, and low-calorie soft drinks. Resorting to liquid calories is an indication that you have developed maladaptive eating (poor eating behavior) and a signal that the band may be too tight and should be loosened.

Energy expenditure in the form of exercise is also necessary to assist with weight loss. An exercise program must take place regularly and should be complemented by a constant effort to remain active throughout all parts of the day.

Weight loss will be a key focus of your results after adjustable band surgery. Inevitably, the primary focus is on the amount of weight that is lost, and we expect that most people will lose over 50% of their excess weight. For example, if your current weight is 250 pounds and your ideal weight is 150 pounds, then you have a total of 100 pounds of excess weight. One half of this is 50 pounds and this is the initial target for weight loss, so our goal is for you to drop below 200 pounds.

This is the average. Some people will have more weight loss than this, and some will have less. We want this weight loss to occur slowly and gently. We are quite happy if we are able to achieve these goals in the first two years after the procedure. Because the operation is adjustable and we can control the amount of stomach restriction, even in later years after adjustable band surgery, weight loss can be achieved. This is in contrast to the gastric bypass operation, in which almost all of the weight loss occurs within 18 months. There is no ability to control any of the settings of the operation after stomach bypass surgery.

The goal of the adjustable band is to achieve good hunger suppression and weight loss without severely altering lifestyle and quality of life. In particular, vomiting is not desirable and you should have a normal living pattern after surgery.

In association with this weight loss, you will have major improvements in your medical problems. Diseases such as diabetes, asthma, high blood pressure, back pain and other joint pains and heartburn are greatly improved in association with the weight loss. If you have type 2 diabetes, the more weight you lose, the less likely it is that your diabetes will come back. If it appears beneficial to attempt to achieve even more weight loss after band surgery in order to control diabetes better, then we will do this. If you have not already been diagnosed with significant medical illnesses of obesity, then you are fortunate and the goal of adjustable band surgery is to prevent these problems from occurring.

You will also be much more physically active and more flexible. You will become more confident and more active socially. Employment prospects are improved, not only because of improved physical appearance, but also because of the much improved capacity for physical activity and the improved self esteem and self confidence.

Weight loss will lead to multiple health, physical, and psychosocial effects on your life. While you may currently feel trapped in an obese body with its various problems, you will find out quite rapidly that adjustable band surgery works in a way that doesn't hurt. It works in a durable fashion and you will finally feel a sense that your obesity problem is controlled. You will be able to live without many of the illnesses of obesity and the limitations that these problems caused in your life.

Adjustable band surgery is very safe, but no operation is free of risk
It can't all be good news. There must be dangers, there must be problems. What is the worst that can happen? Well, there are many negative aspects to operations for obesity in general, and it is essential that you are aware of these.

Any stomach operation for obesity is major surgery and carries with it the risks that would go with any complex operation. People have died from having operations for morbid obesity - it happens rarely but we cannot take away the risk completely. If you are an older male, have a BMI > 50, already have certain diseases due to your obesity, or if you are otherwise unwell you will be at greater risk than another morbidly obese patient who doesn't share these characteristics.

Deaths associated with obesity surgery occur mostly because of heart attacks after the operation, clots passing to the lungs or infection due to breakdown of some part of the stomach wall.

Others may be of major significance and can be associated with a much longer hospital stay and a much longer recovery period. The sorts of problems that are relatively common are infections which may occur in the lung, in the stomach in the area of the band, or at the sites where the ports are placed through the skin.

The risks of laparoscopic banding are generally related to the band, the tubing, and the port.

The laparoscopic adjustable gastric band has been shown to be the safest operation for obesity with death occurring in 1 of every 2,000 patients who has the procedure. There is probably about one chance in twenty that complications may occur at the time of the operation. Some of these are of minor significance and do not slow your recovery significantly.

Clots may also form in the legs and travel, as with other types of major abdominal surgery. The risk of this problem is linked to the length of surgery and the ability of patients to get up and walk immediately after surgery. Because gastric banding is a gentle operation, patients seem to be able to mobilize themselves early after surgery and this helps to decrease this clotting problem.

The stomach can be damaged as the band is placed and perforation of the stomach can follow. Pre-existing illnesses such as diabetes and asthma may become more difficult to manage around the time of the operation. We take a range of measures to reduce the likelihood of problems occurring, but in spite of our best efforts, we are unable to prevent them completely.

A new eating pattern is established after the operation, and during this learning phase you may have episodes of vomiting. Ideally there should never be vomiting after an adjustable band is placed. The force of the vomiting can cause the stomach to shift in its position within the band and the effectiveness may be lost. We have special instructions for eating and drinking in order to avoid vomiting at all, but this ideal cannot always be achieved.

The major long-term concern which we have after surgery is shifting of the stomach through the band. At operation we place the band in a very particular position and we take special measures to fix it in that position.

However, on occasion the stomach can still move through the band and increase the size of the pouch above the band (this is called pouch slippage or pouch dilation). If this happens, you will get abdominal pain, heartburn and reflux of food and fluids. If the enlargement of this stomach continues it can eventually block off and vomiting would occur. This problem can arise months and even years after the procedure. It is more likely to occur if the rules regarding eating and being sensitive to fullness of the stomach are not carefully adhered to. If this happens, a further operation will usually be needed to correct the problem. It may also occur if you ignore some of the early signs of a band which is too tight such as mild reflux, obstruction, or heartburn.

It is also possible for the band to work its way into the inside part of the stomach (this is called band erosion). If it does so it ceases to be effective and all that you will probably notice is that you are able to eat a greater amount without that sense of restriction. It would not be expected to lead to any pain or acute illness immediately. If it happens we would have to operate to remove the band, repair the defect in the stomach and usually we would place a new band at a higher position at a later time.

Our current experience suggests that it would be expected that about 1 person in 10 is going to need a further operation within the first 5 years after surgery. For patients who are expecting to live for a very long time after surgery (30+ years), the likelihood of requiring a revision of one component or another of the port-band system is probably close to 100%, but no one knows yet how long each of the components lasts in the long run.

It is most important therefore that you see the decision to go ahead with the operation as a most serious one and it can only be justified if the problems associated with your obesity clearly exceed the problems that may be associated with the operation. It is not a decision to be taken lightly; it is not like going on another diet - you can always give up on a diet.

Laparoscopic adjustable gastric band placement is an event which occurs, and there is no intention of ever removing it. The band is made of cured silicone, and there are no known side effects from having this material within the body. If the band was removed we would normally expect that your weight would go back to the level it was before the procedure was done.

Although we place the band without any planned intention of removing it, there are three points that you need to bear in mind.

First, we must be able to maintain follow-up with you permanently. We want to see you at least twice a year permanently, to look at your progress, readjust the band, look for any problems and discuss your general heath. If you move out of the Twin Cities metro area or overseas, contact must be maintained by telephone or mail as an absolute minimum. If you are not prepared to make this commitment we shouldn't proceed further.

Second, the band can be removed if necessary. If it is placed laparoscopically, then generally it can be removed laparoscopically. By the nature of the material, it does not stick to other tissues and therefore if some reason develops which makes its removal appropriate, this can be done.

Third, it could be in the future that reasons will develop, either for you as an individual or for all people who have had the band, which make it appropriate that it be removed. We will continue to monitor each person and the information about the procedure itself and as long as we maintain contact with you we can always advise you of this.

Although there is no reason at this time to expect that we would wish to remove the band at any specified time point in the future, we must recognize that, depending on your current age, your life expectancy may be up to 60 or more years. We cannot just assume that the band will be the best option for the treatment of obesity appropriate to be locked into a situation which has to hold for all of that time. Reversibility is one of the attractions of this procedure, since this is possible if necessary. This is not an option for gastric bypass or duodenal switch.

There is a significant amount of adjustable band maintenance
We expect that all patients will return to our clinic 10 times during the first year after surgery. At each of these visits we will decide with you if your weight loss and symptoms of hunger or satiety suggest that an adjustment should be performed. You are not expected to have an adjustment at every visit.

You may read many different ways on the internet about how different surgery teams provide or don't provide appropriate guidance to band patient. It is our basic assumption that patients are typically having band surgery for the first time and do not know when they should need another adjustment. We have performed the operation many times and have seen patients thousands of times after surgery so our surgery team will advise you at each visit when your next visit should occur. We call this a surgeon-driven band assessment clinic (rather than a patient-driven adjustment clinic).

During the first year, there will never be a gap of more than 2 months during which we don't see you in clinic. Together in clinic we will decide with you if an adjustment is necessary or not. Not doing an adjustment for a hungry patient is a lost opportunity to suppress hunger. Adding too much fluid for a patient who already has hunger suppression can cause obstruction and dehydration. Our target is to carefully add the right amount of fluid without ever making you sick.

The first goal of the band assessment clinic is to add enough fluid to the band to provide good satiety control and weight loss of 1 to 2 pounds per week. This is done by adding 4 cc of saline at the first adjustment visit 2 months after surgery and then saline in 1 cc increments at each visit after that until satiety is achieved. Every patient is different so this may take just 1 or 2 visits or as many as 5 or 6 visits.

The second goal of the band assessment clinic is to maintain satiety and weight loss during the period of early rapid weight loss. There are two reasons that additional fluid may need to be added to the band despite a perfect initial fit. First of all, as you lose weight fat is melting from all parts of the body and this includes fat that is located inside the band in the wall of the stomach. Therefore, as you are tightening up your own belt buckle around your waist we also may need to tighten up the band around your stomach. Secondly, the band system will always lose a very small amount of saline every year by the forces of osmosis (the band loses about ½ cc per year). This loss by osmosis means that you will always have a need to be 'topped off' every 6 months or so for the rest of life in order to maintain satiety and weight loss.

Every year we will ask you to have an x-ray to monitor the status of the band and the pouch. We will also order laboratory data annually to make sure that the lower calorie meals that you are eating are not leading to vitamin and mineral deficiencies.

Adjustable band surgery is a proven reliable and durable option compared to other surgical treatments for obesity
Patients who are fully aware of the need for frequent early follow-up (10 visits in year one) and semi-annual follow-up in the years afterwards will have great success in attaining and maintaining weight loss. The average band patient will lose 50% of their excess weight within the first two years after surgery. Younger, active, non-diabetic patients typically lose more weight. Patients who don't show up in clinic according to our guidelines will not lose as much weight.

A review of articles with 3 or more years follow-up demonstrated that adjustable band surgery and gastric bypass surgery had weight loss that was not different at 3, 4, 5, 6, and 7 years after surgery. Gastric bypass has faster weight loss and greater weight loss in the first 2 years, but there is a leveling effect caused by weight gain in gastric bypass and weight stability in adjustable band patients.

Adjustable Band Surgery: Preoperative Work-up, Day of Surgery, and Postoperative Care
Careful Evaluation of Health
After making a joint decision to proceed with surgery, we will ask you to undergo preliminary testing to document your health status, to make sure your routine preventative health screening is up-to-date, and assess any unknown heart, lung, abdominal, or bleeding risk issues in order to make your operation more safe.

There may also be some mandatory dietary consultations that your insurance company will require you to undergo before qualifying for them to pay for your operation.

There will also be a weight loss requirement before surgery in order to reduce the size of your liver before surgery and this also makes your operation safer.

You will visit with nurses before surgery to review the hospital stay and get ready for surgery. Then you will come into the hospital on the morning of surgery about 2-3 hours before surgery. General anesthesia is used and the operation usually takes about 30-60 minutes.

Details of Procedure
The operation is done laparoscopically more than 99% of the time (our practice has not yet converted an operation to open surgery), and so we do not make any large incisions. Long instruments are used to perform the operation inside the abdomen. A special type of camera is passed through one of these ports and allows us to see the stomach with tremendous magnification (high definition). The operation targets just one location in the abdomen and this focused operation avoids handling of the intestines in most situations and causes less trauma to the abdominal wall. This lessens the pain and enables you to get back to your normal activities more rapidly than would occur with other procedures.

There are typically 5 small incisions and 3 of these are about ¼ inch in length and one is ¾ inch in length. There is also one longer incision where the port will be placed. The deep incision which enters the abdomen is ¾ inch in length. The skin incision for the port is located about halfway between the bellybutton and bottom of the breast bone and is just to the left of the middle. This incision needs to be longer at the skin in order to make sure the port sits well on the deep tissue and can be accessed easily in the clinic.

The adjustable band is placed around the upper stomach and creates a small pouch above the band. The lower stomach lies in its normal position below the band. There are no cuts made in the stomach or in the intestine. The stomach and intestine remain in the original pathway.

The operation lasts between 30 and 60 minutes in most situations but may take longer if there are significant adhesions or a hiatal hernia repair is done at the same time.

Immediate Care after Surgery
Pain after laparoscopic surgery is generally mild although some patients may require pain medications. Pain control may be achieved in many cases with tylenol and ibuprofen (motrin/advil) alone.

Patients are encouraged to engage in light activity and continue breathing exercises while at home after surgery.

The small incisions on your abdomen are closed with sutures. Steri-strips (special pieces of tape) are placed over the incisions and can be removed after two weeks. You may shower two days after surgery. You incisions will be checked at your first postoperative visit 1-4 weeks after surgery.

Liquid Intake after Surgery
The goal of early recovery is to return to good health without dehydration. It is rare for patients to become obstructed immediately after surgery. The usual diet advancement starts with clear liquids and these are started immediately after surgery. Additional guidelines are located in our diet guidebook which is available by clicking here [add link here].

First Adjustment
The first adjustment after surgery typically occurs at the 2 month visit. Usually at this point patients have had a full recovery and almost all of the wound healing is done. Appetite has typically returned after the early swelling of surgery has subsided. This adjustment is performed in a 'band assessment clinic' during a 10-15 minute visit. The adjustment itself only takes 1-2 minutes and most of the visit focuses on eating behaviors and goals of the band assessment and adjustment process.

Section 2. Eating and Drinking after Adjustable Band Surgery [back to top]

Click here for a copy of our diet guidebook

Week 1: The Clear Liquid Diet
During the first week after surgery it is important to take in clear liquids in order to let the swelling around your band to settle down and to settle in place, and to avoid stretching the small pouch of stomach above the band.

The clear fluid will go through rapidly so you do not need to expect to feel full. If you do feel uncomfortable after a small amount of fluid, do not take any more until it has passed.

It is important to note that during this first eight weeks you will be asked to drink liquid calories. After the adjustment process starts, you will not be allowed to have any liquid calories. Liquid calories are allowed during this transition phase to ensure hydration and adequate nutritional intake.

Once you are awake after surgery you can have clear fluids such as water and juice. Do not take more than you feel comfortable with. When you are doing well with clear liquids, we will stop your IV fluids. Most patients will go home on the day of surgery or the day after surgery.

Continue a clear liquid diet for the first week after surgery. Slowly sip 6 to 8 cups of liquid throughout the day.

It is important to not take any solid food during the liquid phases as it could block the pathway through the band and cause stomach enlargement above the band.

Week 1 sample liquids: water, iced tea, sugar-free popsicles, frozen fruit pops, clear broth, diluted Gatorade, propel, crystal light, 100% juice (diluted with 50% water), decaf coffee or tea, or Jell-O.

Week 2: Full liquid diet
Once you are able to drink clear fluids without difficulty you will slowly introduce foods that are slightly thicker than clear liquids. Each time you eat you must take a very small amount and wait to see if it leads to any discomfort before proceeding with more.

Week 2 sample liquids:
Clear liquids, skim or 1% milk, Carnation Instant Breakfast (no sugar added or low-carb), low-calorie yogurt, hot cereals (Cream of Wheat, Cream of Rice, Malt-O-Meal) made with low-fat milk instead of water, strained cream soups made with low-fat milk, sugar-free pudding.

Weeks 3 and 4: Pureed diet
During week 3 after surgery you will begin to add more food choices. These foods will be blended or pureed to reduce the risk of nausea, vomiting and band slippage. Remember to keep drinking enough liquids (48-64 ounces).

Try one new food at a time and eat the protein part of your meal first.

Week 3 and 4 sample foods:
Proteins: skim or 1% milk, Carnation Instant Breakfast (no sugar added or low-carb), low-calorie yogurt, strained cream soups, low-fat cottage cheese or ricotta cheese, scrambles egg or egg beaters, mashed tofu, pureed lean beef, chicken, turkey or fish, mashed beans (such as black beans, pinto beans or fat-free refried beans).

Grains and starches: Hot cereals (Cream of Wheat, Cream of rice, Malt-o-Meal, oatmeal, grits), mashed potatoes, mashed sweet potatoes, mashed winter squash.

Fruits and vegetables: 100% fruit juice (add water to dilute) and limit to ½ cup per day. Plain applesauce with no sugar added, mashed bananas, pureed peaches, pears, apricots, tomato juice, V8 juice, Pureed carrots, green beans, beets or other vegetables.

Weeks 5 through 8: Soft diet
During weeks five through eight you will be adding thicker foods to your diet. You should be eating three small meals a day approximately ½ cup in size. Avoid eating between meals. Remember to keep drinking at least 48-64 ounces of fluid per day.

Add new foods slowly. Take small bites and chew all food very well.

Weeks 5 to 8 sample foods:
Proteins: Tuna fish, white fish, shrimp, lobster, crab; chopped lean meats; lean ground beef or turkey; deli-sliced turkey, chicken, ham, roast beef; low-fat cheeses; egg, chicken or tuna salad (with fat-free mayo or salad dressing); hard boiled or poached eggs; tofu; mashed or well-cooked beans (such as black or pinto).

Grains and starches: Mashed or baked potatoes, cereals soaked in milk (like Cornflakes) or hot cereals, well-cooked pasta, low-fat crackers, toast.

Fruits and vegetables: Canned peaches or pears (packed in juice, not syrup), thawed frozen berries (plain, no syrup), bananas, plain applesauce (no added sugar), mandarin oranges, soft melon, soft, well-cooked vegetables.

Week 9 and on:
From this point on you will eat a solid food diet. This time point should coincide with your first band assessment and adjustment and should represent a clear transition in your diet. All calorie containing liquids must be avoided from now on. You should concentrate on foods high in protein and complex carbohydrate and there should be a low content of fats and sugars.

Bread, red meat and rice may be difficult to tolerate. White meats are usually tolerated better.

Eat two or three small meals a day approximately ½ cup in size each. Avoid snacking in between meals.

Continue to drink 48-64 ounces of fluid a day.

Each meal should last 15-20 minutes of eating slowly and chewing well. Meals should not be accompanied by liquids for 30 minutes before and 30 minutes afterwards.

Section 3. Food Guide [back to top]

You can only eat small amounts of food at a time so you have to choose wisely. Concentrate on foods that are low in fat, low in sugars and have good protein content or fiber. Select foods each day such as meats, eggs, fruit and vegetables, whole grain breads and cereals. Remember the laparoscopic adjustable gastric band only works with solid food so you must avoid liquid calories. Choose vegetables rather than vegetable soup and eat an apple rather than drinking apple juice.

Fruits and Vegetables
Aim for two types of vegetables and a piece of fruit every day. You may have to remove skin from some fruits and vegetables.

Bread, Cereals and Grains
Choose wholegrain breads and foods.

Eat 50-60 grams of protein per day.

Remember to:
1. remove all visible fat from meat
2. remove skin from poultry
3. use low-fat cooking methods such as grilling, steaming or boiling.

Dairy Products
Milk and yogurt are liquid forms of calories and should be limited in your diet.

Limit your intake to less than 2 teaspoons of margarine, butter or oil each day. Low fat salad dressings and mayo should be in moderation only.

Try to drink 48-64 oz. of water per day.

Avoid drinking any fluids for ½ hour before and ½ hour after meals. AVOID calorie containing liquids including diet supplements like Slimfast.

Band patients must avoid all food and beverages containing large amounts of sugars such as soda, cookies, cakes, ice cream, chocolate etc.

Section 4. Exercise and Activity with the Adjustable Band [back to top]

An increase in exercise and activity and general levels of activity is essential for success with your band.

Aim for 30 minutes to 1 hour of exercise a day. Make a commitment to maintain an exercise program. Make it part of your life, plan for it and enjoy it. Find activities you enjoy.

Your band works primarily by limiting your food intake. As you start to lose weight it becomes easier to be active. The more active you are the better weight loss you will have. You will be healthier and feel better.

If you are unable to exercise you should not expect as good of a weight loss result.
The most common exercise and one of the best is walking. This is a great starting point for those who haven't exercised in the past.

Activities of Daily Living:
Increasing your daily activities such as work around the house, working, shopping etc. is a way to increase your energy use. Keep active throughout the day. Park your car further away from store and employment entrances. Use the stairs, not the escalator or elevator.

A pedometer is a great way to track your daily activities. Always try to do more today than yesterday and always be trying to achieve a new personal best.

Section 5. Band Assessment Clinic [back to top]

Placement of the band is just the first step in the process towards safely losing weight with the band system. At the time of surgery, no fluid is added to the band.

There are typically no adjustments done during the first two months so that the band can heal well in its position at the upper stomach. There is always some degree of swelling at the time of band placement, and it usually takes a month or two to fully settle down. It is important to ensure that the band heals appropriately in its final location.

You can schedule your first adjustment in the band assessment clinic 8 weeks after surgery. Please make sure that you are confirmed in a clinic with a provider who does band assessments and adjustments as a routine.

This and all subsequent band fills are performed in our band assessment clinic, which is a clinic designed just for band patients. Our goal at assessment is to evaluate for weight loss and symptoms of hunger suppression. Please review the adjustment chart by clicking here to see how we use your weight loss and symptoms to decide if an adjustment is needed or not. The band at all times is too loose, too tight, or just right.

Please review our band assessment clinic form by clicking here.

Too Loose
When the band is too loose, you will experience frequent hunger, looking for food, eating bigger portions, and slow or no weight loss.

Just Right
The band is just right and in the target zone when you are not hungry between meals, when you are not looking for food or constantly thinking about food, and when your weight loss is about 1-2 pounds per week in the first 12 months after surgery.

Too Tight
When the band is too tight, you may have vomiting, reflux, a night cough, or develop maladaptive eating (chocolate, ice cream, and other calorie-laden liquids) in order to pass food through the tight band.

An adjustment is performed using the following steps:
Locating the port
The port is positioned under the longest incision. Most patients will find their port about halfway between the breastbone and the belly button just to the left of the midline. The port can typically be felt without any aids. For the first few adjustments the port may be easier to find when you are lying down and lifting your head off the procedure bed. This tightens up the muscles under the port and pushes the port closer to the skin. We will almost always ask you to tighten up your abdominal muscles by lifting your head or upper chest for the adjustment. There are also other ways to find the port by using a simple handheld electronic device (a "stud finder") or by using x-ray guidance, but these methods are not usually needed.

Saline insertion or removal
The amount of saline that is added or removed from the port is typically decided upon after discussing your symptoms and weight loss with you. For the first adjustment, a larger amount of fluid is usually added (4cc typically) and subsequent adjustments are performed in increments of 1 cc to a total of about 9 or 10cc. Patients who have come quite close to the right fit may have smaller increments of saline added in order to obtain better satiety control without risking obstruction.

A syringe is pre-loaded with the correct amount of fluid to be added. The skin overlying the port is sterilized with an alcohol wipe pad and a 20 gauge non-coring needle (a Huber needle) is passed through the skin and into the port. Entry into the port is confirmed by feeling the titanium bottom on the backside of the port and by aspirating saline from a previous adjustment. For first adjustments we add the first amount of fluid and then we can remove this same fluid to confirm position.

Assessing band for obstruction
Occasionally the adjustable band may become obstructed. In almost all settings, this can be picked up by asking each patient to drink a small amount of water to make sure that at minimum liquids can pass through the band opening after an adjustment.

Schedule next appointment
It is very important that each patient schedules a subsequent visit in the band assessment clinic after a visit. At minimum all patients should always have a follow-up visit within the next 6 months for the rest of life.

Labs and X-rays
We typically obtain laboratory data 3 months after surgery and then annually on the anniversary of surgery. Even though adjustable band surgery does not bypass the stomach or duodenum, there can be pre-existing vitamin deficiencies or developing vitamin deficiencies because of the more restricted amount of vitamins available in your more restricted volume diet.

We typically assess the band for position once after surgery and this is in the form of either an x-ray performed while you are in the hospital or as a barium swallow (upper GI) with video obtained before your first adjustment. At your anniversary of surgery and annually we will typically obtain a routine follow-up barium swallow. If you experience heartburn, abdominal pain, or other abnormal symptoms we will also obtain a barium swallow in order to assess the position of your band and the size of your pouch above the band.

Section 6. The Special Rules of Eating and Exercise after Adjustable Band Surgery [back to top]

There are eight rules which summarize all that we want you to focus on in getting the best result from the procedure. It is of absolute importance that you are able to follow these rules. The success of the procedure requires us to place the band correctly, but it equally requires that you follow these rules. We will list them, and then discuss each in more detail and then list them again.

The Rules of Adjustable Band Surgery
1. Eat three or fewer small meals per day.
2. Do not eat anything between meals.
3. Eat slowly and stop when no longer hungry.
4. Focus on nutritious foods.
5. Avoid calorie-containing liquids.
6. Exercise for at least 30 minutes every day.
7. Be active throughout each day.
8. Always keep in contact with us.

1. Eat three or fewer small meals per day
The Laparoscopic Adjustable Gastric Band works primarily by taking away your appetite. If it is adjusted correctly you should not feel hungry. This may take several adjustments after your first adjustment because each patient has a different setting that works best for them. You may eat up to three times a day. We don't mind if you eat just two meals per day. Many people do not feel like eating breakfast and some will miss a mid-day meal. If you don't feel inclined to eat, don't eat. If you find you are getting hungry between meals, tell us. We will probably consider adjusting the band a little tighter at your next visit.

Your meals should be about ½ cup of food. This amount is the entire meal, not just one part or serving. When you are first getting accustomed to this very small amount of food you should measure the food with a ½ cup measuring cup and after several months you will know exactly how much to eat. It is very important to keep your meals limited to very small volumes. Overeating may cause the small pouch above the band to slowly dilate and the effect of the operation will be lost if this occurs. Large meals may also cause the band to slip.

2. Do not eat anything between meals.
You are forbidden from having snacks, biscuits with your coffee, fruit, or anything. All food must be restricted to mealtimes. One of the most frequent causes for failure of the band is snacking between meals. If you are getting hungry between meals and are tempted to have a snack, you must tell us. It is probably due to inadequate adjustment; you may need more fluid added to the band. Between meals you may only have zero-calorie liquids-water, mineral water, tea, coffee or low-calorie soft drinks. Slimfast should never be part of the band patient's intake.

3. Eat slowly and stop when no longer hungry.
When you have eaten enough you will no longer be hungry and signals from your stomach to your brain tell you that you do not need any more. These signals take time to be generated. Give them that time. Each meal should be stretched out over 15-20 minutes. If you eat rapidly you will already have eaten too much before you realize that you have had enough. However, do not eat beyond 30 minutes. Throw away whatever you haven't eaten at that time. That is the end of that meal and you must have nothing else until the next meal. Try to make each meal last for 15-20 minutes. Try to sense when you have had enough and stop before you feel at all uncomfortable. Use a small plate, put a small amount of food on the plate, and develop the habit of always leaving some of it uneaten.

4. Focus on nutritious foods.
Foods that are high in protein (e.g. meats, especially fish, eggs, dairy products, lentils, beans, nuts) and foods that are high in complex carbohydrates (e.g. vegetables, some cereals) are best. Simple sugars are worst. Be careful with foods that are high in fats as they are a dense form of calories. Be careful with fruits as they contain quite a lot of sugar.
The good foods can come from all the main food groups and include vegetables, meats, eggs, cereals and dairy. There is no need to focus unduly on the particular foods in fine detail. It is not rocket science. It is simply selecting foods that are good (protein and complex carbohydrates), being careful with those that are not so good (fats, alcohol) and avoiding those that are bad (simple sugars). And take a well-balanced vitamin and mineral replacement each day.

5. Avoid calorie-containing liquids.
Any calorie-containing liquids will tend to flow past the restriction of the band and not give you any feeling of satiety. You are then more likely to take too much.

Allowed liquids:
mineral water
tea or coffee (with low-fit milk if you wish but no sugar)
low-calorie soft drinks.

An exception to the "no liquid calorie" rule is a glass of wine with meals, which has been shown to be good for your health and good for your weight loss when taken in a modest amount (1 or 2 glasses per week).

6. Exercise for at least 30 minutes each day.
This is at least as important as all of the other rules. Not only must you take in fewer calories, but you also must use up more calories. Exercise will improve your general health as well. Initially, while you are severely obese this can be difficult, but, as your weight decreases, it becomes easier. As you become fitter and healthier, you get greater enjoyment from exercise.

We understand that not everybody is sports minded and exercise may be something quite new for you. Start slowly and seek to build up activity progressively. Aim to put together 30 minutes or more of moderate-intensity physical activity on most and preferably all days. Walking is ideal to start off with. As your fitness improves, you should progress to more vigorous walking and even jogging, cycling, aerobics, swimming, and light resistance training. As your weight comes down your exercise capacity will increase and your general activities during the day will increase. The more active you are the better the result will be.

7. Be Active Throughout Each Day.
Think of movement and activity as opportunities and not as an inconvenience. Try to be active every day in as many ways as you can. Make it a habit to walk or cycle instead of using the car. Become active in the garden and do things yourself instead of using machines. Avoid sitting down at all cost. You should see sitting down as an opportunity for lost activity.

Try to spend as much time outdoors as possible. We tend to be more active when outdoors. Use a pedometer as a stimulus to show you how your activity level is increasing. If you are using a pedometer, aim to get beyond 10,000 steps per day-this represents a very good level of routine daily activity.

8. Always keep in contact with us.
We want to follow you permanently. There will never be a time when we say that the job of controlling your obesity is done and we do not need to see you anymore. There will always be a need to check your progress, monitor your health, check for nutritional deficiencies, make sure that you understand the rules, bring you up to date with new developments, and adjust the volume of fluid in the band.

There is always going to be a very small loss of fluid from the band over time. For example, if you had 6 mL of fluid present (5 mL = 1 teaspoon) and we checked the volume after a 6-month period, there would probably be about 5.7 mL present. This occurs because the band is subject to the constant forces of osmosis and so a small amount of fluid is lost from the system every year. If 6 mL was the correct volume, you would be starting to get hungry and eat more with a volume of 5.7 mL. It is important for you to understand that this can happen. You must come back to see us for replacement of that small fluid loss. This is one of the main reasons that we want a maximum of 6 months between appointments.

Section 7. Commonly Asked Questions about the Laparoscopic Adjustable Band [back to top]

Will I vomit?
There shouldn't be any vomiting. The operation places a gentle restricting on your eating. If you find yourself vomiting, then there is either something wrong with the settings of the band and it may need to be loosened or there is something wrong with your following the rules of eating and drinking.

Will I be constipated?
Inevitably as you eat less food, then you eat less fiber and bowel activity will decrease. This usually is not a problem but if it does so it is acceptable to take one of the bulk forming laxatives such as Metamucil with plenty of water and this should correct the problem.

Should I take vitamins?
Yes. You may well be taking sufficient vitamins within the food that you are able to take, but as you lose weight you have a particular need for additional vitamins and therefore we strongly recommend that you do take a multivitamin supplement. It is particularly important that the supplement has sufficient folate and iron. We will monitor specific vitamins and minerals such as vitamin B 12 and folate and iron each year after operation to see if any deficiency in these is reoccurring. If they are, specific addition of these will be recommended.

What about my other medications?
In general you will continue to take the medications prescribed. However, if they are in the form of a bulky tablet, it is probably best to break the tablets up to avoid any chance of them acting as a block which could lead to vomiting. Capsules should be OK as they are designed to soften and melt inside the body.

What if I become pregnant?
The band itself should not interfere in any way with the pregnancy. The likelihood of becoming pregnant is probably higher because, having lost weight, your periods are often more regular. Normally we will adjust the volume of fluid in the band early in the pregnancy to ensure that there is optimal nutritional intake for both yourself and the baby. Almost always this means taking fluid out for the first 12 weeks of pregnancy. After the first 12 weeks, we may elect tighten the band up and assist with slowing too rapid weight gain.

Is the material of the band dangerous to me?
We have no information to suggest that it is. There has been concern regarding liquid silicone in breast implants. We have been unable to show in a large number of high quality medical studies that this indeed is true. The band is made of solid silicone. It cannot leak into the tissues in the way that liquid silicone can and therefore we expect the likelihood of problems is even less. However, it could be that information of problems will become available in the future which is relevant to this question. If this occurred we would inform you of it.

How long will the band last inside me?
We really don't know. We have had similar products in use for in excess of ten years and they have not shown signs of failure. However we can't realistically expect a device such as this to last 40 - 50 years. We do expect that somewhere down the track there will be failure of the adjusting balloon in particular and should this occur, the band would need to be replaced. It is going to remain to be determined if and when this should be necessary.

Can the band be removed?
Yes. It is not our intention to ever remove it, but should it become appropriate for whatever reason, then it can be removed. If it has been placed laparoscopically, then it can be removed laparoscopically. After the band has been removed we would expect the stomach to go back to its normal configuration.

What should I do when dining out?
Because of the limited capacity you must restrict yourself generally to an entree (appetizers in U.S.) alone. Eat slowly while those with you overeat with two or three courses. If you are visiting friends it is probably better to advise the host or hostess that you can only eat a small amount to save embarrassment when you reject their carefully prepared food.

May I drink alcohol?
There is a relatively high caloric content in alcohol. It is a liquid and therefore, should be against the rules. However, there are health benefits to a very modest amount of alcohol intake every week, especially if it is wine. An occasional glass of wine is fine in the right social setting or with your family at dinner, as long as your intake is limited to two or three times per week.

Will I need plastic surgery for excess skin folds once I have lost weight?
Most patients don't need plastic surgery after losing weight because the natural elasticity of skin usually takes up the slack pretty effectively. In general, about 20-30% of our patients need an operation to excise some of the excess skin around the waist. We usually wait about two years after weight loss surgery to consider removing the skin. This is typically when patients have lost a lot of their weight already.

What happens if I become ill with the band in?
The band operation is adjustable, which is one of its principal advantages. If an illness occurs which would make restriction of food intake inappropriate, fluid can easily be removed from the band system and nutrition would no longer be limited. After recovery from your illness, then you would be able to have the saline added back and the original restriction is restored and weight loss may resume.

Will I burp after having the band placed?
Not so easily. As we eat we always swallow air and normally we would bring this back up again quite unconsciously. The Laparoscopic Adjustable Gastric Banding interferes with this easy bringing up of wind. It is common in the first few weeks after the procedure for people to notice a difficulty with bloating and the feeling that they want to burp but cannot. This rarely seems to persist as a problem months later. We presume that the stomach below the band changes its shape enough to reduce the problem but for whatever reason it does not seem to continue to be troublesome.

How are the adjustments done?
There is no rush to perform the first adjustment as we want the band to fix itself into place where it is positioned in the operating room. We start to tighten the band 2 months after surgery. This is typically done in conjunction with an upper GI, which is a video x-ray obtained just after swallowing a barium meal.

The adjustments are done in the office, but occasionally we will also use x-ray to assist in finding the port. The adjustment is typically performed in just a couple of minutes. You will be positioned on a procedure table with a pillow at the small of your back. We will sterilize your skin over the port. A fine needle is passed through the skin and into the port. A pre-determined amount of saline is added to the port.

The maximum amount of fluid that the band system can hold is between 10 and 14 milliliters, and the first adjustment typically adds between 3 and 5 milliliters to the system. Different people achieve the right amount of restriction with different amounts of fluid.

After the first adjustment, we typically perform adjustments every 2 weeks until you the band is in the target zone. With this setting, you will not be hungry between small meals, you will not be looking for food or constantly thinking about food, and you will be losing about 2 pounds a week early on and 1 pound a week after 6 months until your weight has become stable.

We anticipate that you may need between 4 and 8 adjustments during the first year after surgery and 1 or 2 adjustments every year afterwards for the rest of life.

There are several reasons that you may require more fluid in the band even though you have already had a perfect adjustment before. First, as you lose weight, fat melts away inside the band as well and so this makes for a looser fit around the upper stomach. Second, a very small amount of fluid tends to leak from the band every year and this requires a small fill every 6 months or so to keep the band opening just right.

Will adjustments hurt?
No, in general they do not. Some patients are more worried about the adjustment than they worry about the operation itself and this is really unnecessary. Each adjustment consists of a poke with a small caliber needle and there may be some mild discomfort as we find and push gently on the port. This usually only takes two or three minutes and does not require any local anesthetic. Adding a local anesthetic injection would add more to the pain of the adjustment than the whole adjustment by itself. You will most likely be comforted by the ease of adjustments after your first one is done.

How much weight will I lose?
Provided that the band is in good position and that you follow-up diligently in our clinic, in theory we can get you to whatever weight we would choose together because of the adjustable nature of the band.

Ultimately, however, our main goal is focus simply on the profound benefits that weight loss will provide for your overall health. We have found that these benefits can be realized by having you lose about half of your excess weight.

The weight loss is relatively slow and gentle, occurring typically over a 24 month timeframe. Our goal is for you to lose 1-2 pounds each week during the first year and 1 pound per week during the second year. More rapid weight loss than this could be associated with undesirable metabolic effects. For patients with even more weight to lose, the adjustable nature of the band allows us to carefully control weight loss over an even longer period of time.

What should I do if am going to travel to a remote location?
In most cases there are problems with this. While away, you will generally want to be especially careful about following the rules of eating and drinking. Take the information about your band with you so that other doctors will know what to do if there are problems. You may always have your treating doctors call us through the hospital operators at any time of day. We are always happy to discuss the problem with them before they do any intervention with accessing the port unless they are already experienced with the device.


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