Band adjustments - Fills

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Band adjustments - Fills

Post  Admin on Tue Aug 03, 2010 1:39 am

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.

Effectiveness
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".

The Royal College of Surgeons of England held a national consensus meeting on the status of bariatric surgery in the UK on 21 January 2010, in the course of which the President, John Black, drew attention to the inequality of access to WLS across the nation (in many strategic health authority areas the NICE thresholds for surgery are being ignored as bariatric service provision is geographically patchy and financial commitment is inadequate).

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