The Lap-Band: Operation is easy, aftercare is critical

May 12, 2013
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There is one thing clear about Lap-Bands: it is taking care of the patients after surgery, teaching them how to use the band, that is critical in how it is used. There have been a number of reports in the literature about centers that have removed bands, didn’t have the results with the bands that many others have reported, and felt that their results with the band must be global results.  Those results are in stark contrast to Lap-Band surgeons who use the band a lot, who have great results with their patients, who see their patients often.

There is one thing clear about Lap-Bands: it is taking care of the patients after surgery, teaching them how to use the band, that is critical in how it is used. There have been a number of reports in the literature about centers that have removed bands, didn’t have the results with the bands that many others have reported, and felt that their results with the band must be global results.  Those results are in stark contrast to Lap-Band surgeons who use the band a lot, who have great results with their patients, who see their patients often.

The reason for this is simple: those who do not know how the band works, those who do not use the band that often, should not be offering the band as a weight loss procedure. What is even more sad is some of those individuals who have undergone lap-band surgery and develop a band slip, are having their bands removed and being converted to a gastric sleeve (where 90% of the stomach is removed).  Those patients are being told that the band didn’t work for them, that they failed the band, or the band failed, and that this is the best result for their obesity.  Many of those patients have had long-term success with the band.

When a band is first placed in the top part of the stomach you can see a normal appearing x-ray. The key to teaching patients about how to take care of the band is to enforce that the band is NOT ABOUT RESTRICTION. The band does not, and should not restrict food going past it. Instead the band should allow food to go freely past the band. If food stays above the band too long, it will become uncomfortable. Ultimately this causes stretch with the stomach on top of the band and begins a process of dilation and as the stomach above the band dilates, it begins to pull stomach from below up to the band.

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Once this happens there is what is called a band slip.  It is at this stage that some surgeons mistakenly remove the band and convert patients to a gastric sleeve. Converting to a sleeve in these circumstances comes with a 5.5% leak rate- meaning, it is far more deadly.

There are two alternatives, however.  One alternative is to remove all the fluid from the band and place the patient on a strict liquid diet for a week.  Recheck an x-ray and often times the band will be back in a normal position. During this time the patient needs to be educated about how to use the band, and not use the band. Behaviors that cause slips include: relying on the band to feel full, eating too fast, getting foods stuck too often. The most deadly is relying on the band to make a person feel full.  If they do this, they will cause the stomach above the band to stretch, as it stretches stomach is pulled from below the band to above the band and result in a slip.

The second alternative is a surgery to unbuckle the band.  This takes the pressure off the upper stomach.  There is scar tissue from where the band and the stomach were and that scar tissue must be opened up.  This is a quick operation, takes about ten minutes, and allows the person who could not eat or drink to immediately be able to.  Then, in two months the patient has a choice to have the band re-buckled, leave it alone, or if they wish to go to another weight loss operation there is much less risk of a leak. We have done over 20 patients with unbuckling the band, and later repositioning it. All with great results, no morbidity or mortality in that group.

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The key, however, is having a band surgeon who knows how to take care of the band, and not a surgeon who is quick to abandon the band and not wish to teach the patient how to use it.

Here is the problem with the gastric sleeve: it will stretch over time. Having done hundreds of sleeves, after four or five years we see that they stretch, and sometimes will stretch back to the size of a normal stomach. That same behavior that caused the stretching of a pouch above a Lap-Band will ultimately lead to stretching of the sleeve — then the patient is faced with another choice.  A number of my patients who underwent duodenal switch, or gastric sleeve, years ago and had their stomachs stretch, have had the lap-band placed over them, with great results.

Great results are not from the procedure: it is from teaching patients about aftercare and lifestyle.

That is the key to having success with the least invasive operation. Not that there are not complications with surgery- as there are with any operation – but it is quite clear: there is a huge difference in the results of those who have a band done from a center where they specialize in the band and the aftercare of the patient, and those centers where they offer a band but are quick to abandon it.

Lap Band

The lap band is placed at the top of the stomach – here is a diagram of the band placed in its normal position

Band x-Ray
This is a normal band x-ray. The band is the faint outline in a 8oclock to 2 oclock position, there is normal contrast going through it.

Band Slip
Relying on food to go slowly through the band, and having the band too tight means food stays above the band. Some people say this makes them “feel full” but it ends up causing a band slip

Total Slip
Once there is enough stomach above the band, it flops over the band – like a muffin top. At this point patients experience heartburn, reflux, sometimes night cough

Band slip x-ray
The x-ray shows the band now in a 10 oclock to 4 oclock position, with the stomach pulled above the band, and the muffin top

Unbuckled band
Here is a diagram of an unbuckled band. Below the band, on the stomach is the scar tissue which must be lysed (or cut) to allow healing