Gastric banding in detail

What is gastric banding? 

Figure 1 - Lap band in position in the upper part of the stomach.

The operation involves placing an inflatable band around the top of the stomach to create a much smaller stomach, called a pouch, with a narrow opening, called a stoma, though to the rest of the stomach. (Figure 1)

The size of the pouch limits how much food you can eat at one sitting, and the width of the stoma limits how quickly the food leaves the pouch and enters the rest of the stomach. The gastric band is usually inserted laparoscopically (by keyhole surgery) and takes less than an hour to perform. This typically involves making five small cuts on your tummy, to insert the camera and instruments for the operation. The band encircles the upper part of the stomach and is connected by a tube to a small reservoir port that is placed under the skin of your abdomen. (Figure 2)

You will be able to feel this yourself under the skin with time, but it is not usually obvious to see. This operation can be done as a day case but most patients will stay one night in hospital.

 

  
Figure 2a & 2b - Allergan adjustable gastric band

How does the gastric band work?

The gastric band forms a constriction ring around the upper stomach so that you only have to eat a small amount of food before you start to feel like you've had enough. The tightness of the constriction is adjustable as the gastric band can be inflated or deflated by injecting or withdrawing sterile salt solution with a needle and syringe via the small reservoir port under your skin.

The gastric band itself does not make you lose weight. By restricting the amount of food you can eat at one sitting, the gastric band really just provides a daily reminder of your commitment to changing your lifestyle and eating behaviour. There is no escaping from this. You need to stay on a healthy, restricted diet to lose weight and the gastric band simply helps you to do this.

How do we know how much fluid to put in the gastric band? How much restriction should it produce? The ideal is that you feel full after eating a small plate sized meal, this feeling of fullness lasts for several hours and you are not hungry. If you can eat larger meals and not feel full, then we need to add fluid to tighten the gastric band. If you find you are getting a lot of heartburn, feel sick after eating a few mouthfuls, and if liquids take time to swallow, then your gastric band may be too tight and need fluid taken out.

You should look upon your gastric band as a lifelong contract:

  • The gastric band's job is to restrict your eating to help you lose weight, and keep the weight off once you have lost it

  • Your job is to stick to the rules about diet and exercise

There are not many of these rules really. Remember that liquids will pass through the stoma quickly, so if you take a lot of calories in liquid form - like juice, alcohol, ice-cream or chocolate - your gastric band may not work! Our dietitian will advise you about what you should and shouldn't eat.

The gastric band needs your participation - remember that it is no more than a tool which will help you adapt your eating behaviour. A lot of responsibility for its success still lies with you. Therefore it is essential that you adhere to your
dietary programme and continue to meet with your medical team so that they can monitor your progress and provide any additional support you need. It's also important that your friends and family provide emotional support and do their bit to help you maintain your new healthier lifestyle.

Alternatives to gastric banding

It would be better to avoid surgery altogether. Making major lifestyle changes to include dieting, healthy food choices and regular movement and exercise will be required after surgery anyway, and many people find that these things alone help them to lose weight without the need to undergo an operation. Others find that the addition of prescribed weight loss drugs such as Orlistat provides all the help they need to get their weight down.

If these things don't help, or the effects don't last, it is reasonable to consider weight loss surgery. Then the major consideration becomes which operation is best for you. Apart from the gastric band, current surgical options include the
gastric bypass, gastric sleeve, duodenal switch or the gastric balloon (see other sections).

Benefits of gastric banding

Apart from the gastric balloon procedure (which is done under sedation and not really an operation at all) gastric banding is the quickest and safest of the weight loss operations. It is generally done as a day case or overnight stay in hospital. The gastric band does not cause permanent changes to the digestive system. It does not involve cutting/joining the stomach or the intestines, thus is it potentially reversible - that is, if the gastric band has to be removed for any reason, then you are no worse off that when you started.

For most patients who have gastric banding, the health benefits from losing weight are much greater than the health risks of the operation.

Risks of gastric banding

Inserting a gastric band involves a surgical operation. There are thus the risks of the general anaesthetic, and there are the risks of the operation itself.

Modern anaesthetics are very safe, but being overweight does add a slight risk when having a general anaesthetic, and if you have other illnesses such as diabetes or heart disease (for example) then the anaesthetic risk is a little higher again. At Weight Loss Surgery Scotland you will undergo a careful preoperative assessment where any potential risk factors are identified. Other specialists can be called in for opinions if required, and the consultant anaesthetists will meet you to discuss your anaesthetic beforehand. The hospital operating and anaesthetic facilities are state-of-the-art and all precautions are taken to reduce the risks.

The surgery is carried out on the upper stomach, which is very close to the liver, spleen and bowel. Damage to these or other organs during the operation is possible, but very uncommon. Bleeding may occur but is not usually much of a problem as long as it is recognised and fixed. The need for a blood transfusion as a result of a gastric band operation is highly unlikely. Similarly, perforation of the stomach or bowel is not usually of major concern if the perforation is recognised and fixed.

The other main risk of surgery is blood clots. This can happen to anyone having any operation, not just a weight loss surgery operation. Every attempt is made by the Weight Loss Surgery Scotland team to minimise this risk around the time of your operation. We do this by using injections to thin the blood, as well as special stockings and calf pumps during the procedure. Getting you up out of bed and moving as quickly as possible after the operation is also important to keep the blood circulating in your legs.

Complications of the gastric band operation

Gastric band slippage
It is possible for the gastric band to slip out of position. If some of the stomach slips up through the gastric band from below, it causes a much bigger pouch and the stoma can become very narrow - or indeed block altogether. Very occasionally, the slippage can damage some of the blood supply to the stomach

Gastric band slippage can be corrected but this involves returning to theatre for another operation. Sometimes, the band has to be removed. Early gastric band slippage can occur if you vomit a lot after your surgery. The best way to avoid this is to stick to the diet instructions you are given.

Pouch dilation
If you regularly overeat, the pouch will stretch up and get bigger. This will mean you can eat bigger meals, so you lose less weight - and may begin to put weight on. Sometimes, if picked up early, more careful eating behaviour can reverse this dilation.

Gastric band erosion
The gastric band is made of very soft plastic. However, it is a foreign body. It can thus rub on the stomach, and occasionally in time this may rub a hole (erode) into the stomach. The inflammation associated with this narrows the stoma making it difficult to eat. If gastric band erosion occurs, the gastric band has to be removed.

Gastric band infection
When a gastric band erodes into the stomach, it becomes infected and has to be removed. Alternatively, the port under the skin may become infected. Every time you have a gastric band fill, there is a small risk of infection. The port and the band can also become infected spontaneously. Antibiotics can sometimes treat the infection, but often the gastric band has to be removed.

Is my gastric band in for life?

Yes, the aim of the operation is to leave your gastric band in for life. However, it doesn't work for everyone and some people eventually have it removed for this reason. Also, some of the complications which may arise may require its removal

Will you keep me under review?

Figure 3 -
The gastric band does not affect the
rest of your intestinal system

Yes. There is good evidence that patients who have the best results are those that have the most active long term follow up.

For the first few weeks after the operation we keep in close contact as you recover and begin to adopt your new eating patterns.

Six weeks following your operation you will have your first band fill. This is when fluid is injected via the port under your skin to inflate the gastric band further. This first band fill is done in the X-ray department, which allows us to make the band fill as accurate as possible. You will have further band fills every few weeks over the next 3 to 6 months until the level of constriction is just right. These further band fills are usually done in the clinic without the need for X-ray. After each band fill, you need to revert back to a liquid/sloppy diet for a few days before gradually reintroducing more solid food.

After that we recommend that we should keep seeing you every six months - for life.

The gastric band and the tubing will lose small amounts of fluid each year. As the fluid slowly leaks out (it is sterile salty water so will not cause you any harm) the stoma size will increase and food will leave the pouch more quickly, so you find you can eat more. You lose less weight. So the gastric band needs continual review and occasional top-ups of fluid.

There are times when the gastric band needs to be deflated too. For example, if you are travelling overseas for a long period we might loosen the gastric band deliberately just to prevent any eating problems while you're away.  Also, if you get pregnant (and losing weight does help your fertility!) then we would loosen the gastric band to ensure that you can get enough nutrition for the baby.

You will be able to eat most foods with time. Your intestines and digestive system are still normal (Figure 3); however we recommend that you do take multivitamin tablets (which often contain other important things like iron and calcium) to minimise the risk of deficiencies, because you will be eating LESS. We would plan to do blood tests once a year to check on your nutritional status.