Laparoscopic Gastric band surgery (Lap-band)
Lap Band is the most common form of weight loss surgery in Europe and Australia. Recently approved by the FDA, it is usually performed laparoscpicaly. It is one of the least invasive approaches to obesity because neither the stomach nor the intestine is cut.
To date more than 150,000 Lap-band surgeries have been performed. Since the Lap-band is implantable using minimal-invasive techniques ("keyhole techniques"), patients that are extremely obese with heightened surgical risks benefit from the conservative entry to the abdominal cavity. Due to the absence of upper abdominal incisions, the incidence of wound-healing complications, wound infections, postoperative pain as well as incisional hernias are drastically reduced. In addition, this method is cosmetically advantageous due to the absence of a large scar and it is fully reversible. The absence of lasting modifications to the anatomy of the intestinal tract allows for relatively easy restoration to the original state by simply removing the band, which can be done using laparoscopic techniques in most cases.
The band is applied around the stomach about 20 mm below the gastro-esophageal junction. On the inner lining of the band there is a longitudinal balloon (like a bicycle tire). This balloon is through a small tube attached to a subcutaneous port. The band is left empty at time of surgery but is thereafter gradually filled with fluid by injection through the subcutaneous port. It is thus possible to vary the opening in the stomach after surgery.
The balloon band system can be regarded as putting a straight-jacket on the stomach. The small gastric pouch created above the band limits the amount of food that a patient can eat at any one time, and will result in a feeling of fullness after eating a small amount of food.
The band induces an early feeling of satiety and thereby decreases food intake. Our method as well as other methods for obesity surgery does not however change the basic patient behavior pattern. If the band is removed the weight will quickly increase to what it was before surgery. This means that the operation is not a definite solution to the patient eating pattern or the problem of morbid obesity. It however induces sustainable weight loss and therefore it leads to a healthier life with fewer risks for obesity related secondary diseases.
The amount of weight you lose depends both on the band and on your motivation and commitment to a new lifestyle and eating habits.
How does the gastric band Work?
The Lap-Band System involves the laparoscopic placement of a hollow silastic band around the upper part of the stomach. This band divides the stomach into a small upper pouch above the band and a larger pouch below the band. The band can help you achieve longer-lasting weight loss by limiting the amount you can eat, reducing your appetite and slowing digestion.
Adjusting the size of the opening between the two parts of the stomach controls how much food passes from the upper to the lower part of the stomach. This opening (stoma) between the two parts of the stomach can easily be decreased or increased, by injecting or removing saline from the band. The band is connected by a tube to a reservoir placed beneath the skin during surgery. The surgeon can later control the amount of saline in the band by piercing the reservoir through the skin with a fine needle. Being able to adjust the band is a unique feature of the gastric band and is a normal part of the follow-up.
Expected Weight Loss
In general, most patients find that they are unable to easily tolerate red meat, pasta, rice, fresh bread and fibrous foods. You will be asked to eat three meals a day with one planned snack, chew your food very well and swallow slowly. You must only drink either no or low caloric beverages and wait at least one hour between eating and drinking.
Success rate in term of weight loss is heavily dependent on choosing the right surgeon, the right patient, post op regular follow up including monthly band adjustments and nutritional counseling. We have more than an 85% success rate in term of losing 50% of the excess weight within the first six months. No wonder that gastric banding is gaining huge popularity around the world and surgeons in the United States are reporting an eight months waiting list for the surgery.
Preparing for surgery
If the patient is a heavy smoker, surgery should not be contemplated unless the patient enrolls in our smoke cessation clinic. A two week fat free diet before surgery reduces the amount of fat around the liver. Once the liver shrinks, the operation becomes technically easier and safer.
Patients whose weight exceeds 170 Kg are asked to lose weight with the help of medications and other interventions as the procedure carries much more risk when weight is higher.
The patient undergoes full investigations including ultrasound of the liver and gallbladder where stones are frequently found. Blood tests and heart tests are done. Common findings such as a hiatal hernia causing heartburn or stones in a gallbladder can be fixed at the same time.
Here are the short-term side effects of the operation:
Most patients will once or twice feel pain or vomit after intake of food. This is in most cases caused by eating too much and too quick. If eating is slow and calm, patients will learn to listen to the signals from the stomach. Eating should be abandoned if the patient feels nauseated, have pain or vomits. Regular vomiting is a sign of warning. This can either be caused by wrong eating behavior or be caused by the outflow of the gastric pouch becoming too narrow. This means that the band may need to be adjusted through a tinny needle stick introduced into the reservoir under the skin. Regular vomiting should be discussed with the physician in charge and corrected.
Many patients feel constipated after surgery. This is mainly caused by the fact that the reduced food intake leads to less feces and it is thus normal with 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.
Many patients report increased hair loss during the first six months after surgery. This is also caused by the relative starvation. This however never leads to baldness and normal hair growth will eventually return.
Serious complications are not common especially when the surgeon is experienced with this kind of surgery. At the Emirates Hospital in Dubai where I work, our team is headed by Dr. Christian De Bruyenne. He is a leading advanced laparoscopic surgeon in Europe. This surgery was approved in the USA in late 2003 and thus American surgeons who are more experienced in gastric bypass are less experienced in this operation than the Europeans.
Over the last eight years Dr. Christian has performed more than 1,650 successful operations without a single mortality. Complications such as perforation of the bowel or stomach are encountered every two hundred cases in the hand of an experienced surgeon but are much more likely in the learning curve of less experienced surgeons. Should that happen, re-operation is required with a 2-3 week hospital stay. The operation is done under general anesthesia and lasts for about one hour and the patient usually goes home in 24 hours. The patient must follow the strict instructions in the two months period after surgery to minimize vomiting and complications and must follow up with our dietician.
One in 50 cases requires blood transfusion due to a perforation of a small blood vessel. Leakage of the port or rubber tube connecting the water reservoir to the band is seen in one out of thirty patients and is easily fixed with a minor revision usually under local anesthesia. Other rare complications may arise including slippage of the band, erosion and infection which may require repeat surgery. Most of the repeat surgeries are done with simple keyhole surgery.
An infection would require a prolonged hospital stay and may require re-operation and even removal of the band usually through the same previous openings. Infections are rare five times less in surgical hospitals such as the Emirates hospital which by definition does not accept patients with chronic diseases or chronic infections than in general hospitals.
Although we use the latest improved FDA approved bands it must be pointed out that a definite guarantee against manufacturing defects can never be given.
Migration occurs when the band and balloon migrates through the stomach wall into the stomach lumen. These cases are outright failures and these patients have quickly regained their preoperative weight. The French band we use (Cousin) has been associated with much lower migration because it is a low pressure system compared to the old bands. Migration usually does not occur until 18-24 months after surgery. Patients who have their bands filled quickly and with high total volumes have an increased risk of migration. Filling must be slow and gradual. If these guidelines are observed the frequency of this type of complication will decrease. So far we have not had a single case of migration.
There have been port problems in about 4% of the cases. There are two types of problems. The first is dislocation of the port. It may move around, turn up-side-down and can in this position not be injected. It is thus necessary to adjust it. This is a simple operation in local anesthesia but nevertheless a nuisance to the patient. The second problem is perforation of the connecting tube close to the port. Some patients have extra fat over the chest and it is therefore sometimes difficult to hit the ”bulls eye” with the needle and the tube may be accidentally perforated. This leads to loss of fluid, widening of the opening and subsequent weight gain. This is also corrected in local anesthesia. The port is brought to the surface, a bit of the tube including the hole is cut off, and the remaining tube is reattached to the port and finally the port returned into position. The design of the system has because of this problem been changed. The distal 2 cm of the tube is now covered with a protective sleeve in order to avoid this problem.
Post operative considerations
Diabetics who have previously been on insulin should be managed carefully with a "sliding scale" protocol to avoid hypoglycemia. It is not unusual for a patient to drop from 90 units per day to 8 units on the first post-operative day and require no more anti-diabetic therapy after four days.
Even though the initial pouch is about 20 - 30 ml, or the size of a man's thumb, most patients can eat a half hamburger, several French fries, and drink a small soft drink at one time within about six months after the operation. Curiously, it is rare to encounter a patient who complains about not getting enough to eat.
Patients should resume regular exercise which is much easier to do once their weight drops 30-40 Kg. They should avoid fizzy drinks and minimize caffeine and cigarettes. The esophagus should be checked on a yearly basis with an X ray as the esophagus may widen or distend if the band is kept very tight for more than a year. Should that occur, relaxing the band for a few months will take care of the problem.
When you consider the possible complications of morbid obesity such as:
Coronary heart disease
Osteoarthritis (Back, hip and knee pain)
Non-alcoholic steatosis (liver scarring)
Increased accident rate
Infertility and impotence
Loss of the menstrual period
Focal glomerulonephritis (kidney failure)
Soft tissue infections
You would then understand that gastric banding, while it has some serious risks that can be minimized in the hands of good surgeons working with a good team, carries a lot less risk than staying obese, or worse continuing to gain weight.
Frequently asked questions regarding the adjustable gastric band.
Q. I feel pretty discouraged and hopeless about my weight. I hardly ever go out, feel ugly have low self esteem. If I lose all this weight, how will my life change?
A. Of course, we can't predict exactly how your life will change after losing 35, 50 or 75+ Kilograms. I can assure you that your life will change and the changes are very likely to be quite dramatic! Over the years that we have monitored our patients, we find that some of the major changes to be:
Improved physical status, for example, blood pressure, blood sugar and respiratory regulation), more energy, less body aches and pains, improved sleeping.
Improved psychological status, including decreased depression, improved self esteem, improved social skills, more confidence and realistic hope for the future.
Changes in relationship, including family, love relationships, friends and co--workers. In general these changes are positive and exciting. They are also demanding. In order to cooperate with our program, patients must really put their own health care choices first. This is very often a change for our patients, since many have felt depressed and hopeless they have given their own lives the lowest priority. Our patients have to learn to make assertive, healthy decisions for themselves, even when these decisions upset their loved ones. For example, they may choose to go on their exercise walk instead of sitting down and eating pretzels, or they may have to deal with their spouse's jealousy or discomfort when they become increasingly attractive and independent.
Body image: Patients undergo incredible changes in how they see and feel their bodies. Losing 100 or more pounds creates drastic changes in body size, appearance, and related areas such as dressing choices, feelings of being attractive and sexy.
Accepting normal body image is sometimes a major challenge for obesity surgery patients! Even though wearing a size 8 dress may be a lifetime goal, some patients require some adjustment time to accept this reality, sometimes still "feeling fat", or worrying that they will gain weight back. We find that as more time passes and patients learn to become experts in managing the program guidelines with their individual lives, they experience more real success, and the new healthy body image becomes more comfortable and relia
Q. Is there any scaring after surgery?
A. There is minimal scaring after laparoscopic surgery. However - if you loose 50 Kg you will need a tummy-tuck. That produces a long scar along the entire abdominal midline. After a tummy-tuck the scars will thus look the same whether you have had laparoscopic or open surgery.
Q. How many days in the hospital, and how much down from work is necessary?
A. The patient normally spends one night in the hospital, and can generally be back at work within three to six days.
Q. How does the body know when to stop losing weight? (I don’t want to look anorexic)?
A. Food is the same thing as gas in your furnace. If you have a bigger house you need more gas to heat it. If you have a small house you need less. So - every human being sooner or later reaches a steady state in terms of weight. You will continue to loose weight until your intake is equal to what your body is consuming. The smaller you get the less you consume, and eventually you stop loosing weight. We know, from experience, how much bowel should be out of loop so that your intake is on an appropriate level. I am a compulsive and emotional eater - do people that eat for these reasons have as much success as the ones who just happen to have large appetites (and aren't compulsive)? I fear that this band will not work for me because one of my worst compulsive tendencies is to eat ice cream, which doesn't seem like it would be restricted by the band.
The results might be inferior, but there is no rule. I have patients with the same problem who have had excellent results.
Q. How does the band affect reflux and heartburn?
A. The heartburn you have right now is caused by reflux of gastric juice up to the esophagus. The acid in the gastric juice is not produced in the whole area of the gastric mucosa. It is produced in something called parietal cells. The upper limit of presence of these cells is about 2 inches from the gastro-esophageal junction. The band is placed above these cells. This means that the band actually prevents acid from running up in the esophagus. The second factor of importance is the hiatus (the opening in the diaphragm through which the esophagus goes up into the thoracic cavity). In most individuals the hiatus is tight and no gastric juice is allowed to pass up into the esophagus. In many obese individuals the hiatus muscle becomes slack - so reflux is actually a complication to obesity. When we perform gastric banding we usually tighten the hiatus muscle with a couple of sutures. The result of both these factors is those obese patients who have esophageal reflux in most cases experience an instant relief of those symptoms after surgery. The hiatus is tightened and the band prevents the acid from running up. Reflux disease can occur later as a result of dislocation of the band. If the band moves down it comes below the upper limit of the parietal cells and acid is produced above the band resulting in reflux. This nowadays not so common and we always try to prevent dislocation of the band by suturing it in place.
Q. Will I have excess flab all over my body and need cosmetic surgery later?
A. You will probably need to have a tummy tuck later.
Q. Can I get pregnant with the band and would the baby receive enough nutrients from me?
A.Oh yes - no problem. You will in fact have easier to become pregnant and your child will be healthier because you will have lower blood sugar. It is good to wait about six months after surgery before getting pregnant so that you get over the first phase of rapid weight loss after surgery. There are no special dietary requirements after surgery. The rule is that the baby always takes what he/she needs. So, you can feel confident that there are no problems with pregnancy should you decide to have surgery.
Q. How long can I keep the band in my body?
A.You can keep the band for 10-20 years. You should not consider removing it unless you are sure your weight is stable and you do not need it anymore. We remove the band through a scope via the same previous small scars we used to place the band previously.