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Correct and
sensitive adjustment of the band is imperative for weight loss
and the long term success of the procedure. Adjustments (also
called "fills") may be performed using an X-ray fluoroscope so
that the radiologist may assess the placement of the band, the
port and the tubing that runs between the port and the band. The
patient is given a small cup of liquid that contains 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 may be required.
In some circumstances fluid is removed from the band prior to
further investigation 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 one 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 size is usually determined by personal preference of the
surgeon who places the band together with what s/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, for example, 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 choose to place a small amount in
the band at the time of surgery. The stomach tends to swell
following surgery and it is possible that too great a
restriction would be achieved if filled at that time. 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 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 this 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 and gastric bypass 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.
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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. This comes to roughly 22 to 45
kilograms the first year for most band patients. It is important
to keep in mind that while most of the RNY patients drop the
weight faster in the beginning, some studies have found that
LAGB patients will have the same percentage of excess weight
loss and comparable ability 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. However, with greater
experience and longer patient follow up, multiple series are now
being reported that have found suboptimal weight loss and high
complication rates for the gastric band, particularly when used
in younger patients.
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".
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