Alternatives If the Band Fails

While the problem of a "slipped band" can be effectively managed by repositioning and resuturing the same band, there is a risk that the problem will recur in the future. Many surgeons adhere to the aphorism "Once burned, twice shy!" and recommend gastric bypass surgery for patients with slipped or herniated bands. Without a doubt, this option should be discussed with the patient prior to the second surgery.

The excision of the band in conjunction with a gastric sleeve resection has also proven effective in these instances. The gastric sleeve, unlike the gastric bypass, eliminates the need to rearrange the small intestine. It is also a restrictive procedure similar to the AGB, minus the band. Nevertheless, a large portion of the stomach is removed on the hypothesis that it produces hormones that cause hunger, so reducing the overall size of the stomach is likely to assist the patient in losing weight. This surgery prevents malabsorption complications because the digestive system is preserved.

A disadvantage of the sleeve is that it can stretch over time, allowing the patient to consume larger quantities of food once more. Once stretched, it cannot be altered or tightened in the same manner as a band. The gastric sleeve is an excellent alternative for patients who have experienced complications with the band. It is crucial to remember that there is no such thing as a flawless bariatric procedure. No procedure is accompanied by a guarantee. Any operation can fail, particularly if the patient is unwilling to make the necessary dietary adjustments.

Band Erosion

Erosion is possibly the most severe problem directly related to the band. The pressure of the band on the stomach wall can effectively wear a hole in the stomach wall over time, allowing stomach contents to escape. If an ulcer develops in the stomach lining adjacent to the band, it could potentially penetrate the entire stomach wall, establishing a connection between the stomach's interior and the band.

Typically, band erosions occur months or even years after the band surgery, when significant scar tissue has already formed, containing the gastric fluid in the area immediately surrounding the band. However, bacteria in the fluid create an infection around the band. Patients with erosions typically experience fever, back pain, and dietary difficulties. Some patients, however, experience few, if any, symptoms from the erosion of their band and may be oblivious of the issue. Eventually, the infection will spread along the band tubing, causing pain, redness, and edema around the patient's port. This "red flag" strongly implies that erosion has taken place.

Typically, an X-ray of the upper GI tract or an endoscopic examination will corroborate the presence of an eroded band. If the band has genuinely eroded, the only alternative is to remove it. The infection will not resolve, regardless of how many antibiotics are administered, until the foreign object is removed. Typically, it is not possible to merely repair the erosion and install another band. That is inviting disaster. It may be feasible to perform either a gastric bypass or a gastric sleeve at the same time, depending on how inflamed the stomach is and whether the surgeon believes it is safe to conduct an additional operation.

Checklist of Warning Signs and Symptoms to Report to Your Surgeon

Redness, pain, or swelling in one or both legs

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chest discomfort or difficulty breathing

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Inability to consume fluids

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Persistent acid reflux

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Persistent regurgitation or retching

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Pain, inflammation, or erythema at the injection port site

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It is unknown precisely why erosions occur. Some surgeons have hypothesized that it is caused by trauma to the outermost membrane of the stomach wall during surgery. Others propose that it could be due to ulcerations in the stomach lining at the site of the band caused by the pressure of the band or even ulcer-causing anti-inflammatory medications. Regardless, all potential AGB patients must be aware of the possibility of erosion. They occur in less than one percent of AGB patients, which is fortunate.

Tracey's Tale

Back in 2003, I decided in just six days to form a band. It had to be removed a year ago, but I'm working on acquiring a replacement as soon as possible. Here is what transpired.

I initially weighed 357 pounds and am 5 feet and 1 inch tall; therefore, my BMI was 67.5. At the time I checked into the bypass, neither it nor a band were covered by my insurance. Since the band is so much cheaper than a bypass, and it was even cheaper in Mexico, I chose to have it done in Tijuana.

I lost 96 pounds in my first year. Then, my weight loss slowed significantly.

Initially, I'd like to state that I made a hasty, uninformed decision. The worst aspect for me was the lack of a local band doctor. I returned to Tijuana for my first fill, but I fell behind the band in terms of regular fills, so I did not continue to lose weight. I was able to locate two filling band physicians in Oregon, where I reside. But I

I didn't like one of the doctors because I believed he was unfriendly and impatient, so I chose the other one.

I was planning to get another fill when I discovered I was expectant. This was my fourth pregnancy and C-section. My obstetrician suggested that I have the fluid removed from the band during my pregnancy, but I said I didn't see a reason to do so as long as the infant is growing and not in distress. So we abandoned the fill I had, and my infant is healthy. And the C-section went smoothly as well. The difficulties arose later.

In April 2005, two weeks after my C-section, my port became hot and distended. In addition, the band doctor I was seeing departed his office. I therefore visited my primary care physician. She lanced the port and evacuated the fluid that had accumulated there. The harbor site never recovered. In retrospect, I probably should have visited the other band specialist, the one I disliked, sooner. However, I waited and collaborated with my primary care doctor.

From May 2005 to almost December 2005, I made routine visits to my primary care physician and took antibiotics for the port site. I felt no discomfort. I didn't have a fever. And I did not experience any eating difficulties, such as being able to consume less or more. The port site remained warm and slightly distended to the touch. I spoke with my insurance provider about replacing the port. They stated that they would pay to remove the port to clear the infected area, but they would not pay for a replacement port or to install it.

In November, my primary care physician opined that something was amiss with the port and that I should seek out a band doctor. I felt I had no alternative but to visit the band doctor I disliked. The second time I saw him, he was much friendlier. It turns out he was having a terrible day the first time we saw him.

The endoscopy revealed that the band had eroded through 60% of my esophagus. That is to say, I had band erosion. The only option he had was to eliminate the ensemble. As it posed a threat to life, the insurance company covered the removal surgery. From January to May, the port site ultimately recovered.

Aside from what appeared to be a minor infection at my port site, I did not experience a number of symptoms that would have indicated something more serious was wrong. Since then, I've encountered other band patients; within three or four months, there were five of us with erosion, and we all had bands placed within a few months of one another. I had been in good health for two years prior to my C-section. I believe I wouldn't have had a problem if I hadn't gotten pregnant, but I'm not certain. 1.5 ccs of fluid were contained within a 4 cc band.

I've been separated from the ensemble for one year. I had dropped to 248 before experiencing erosion. I currently weigh between 268 and 270 pounds. I hope to acquire another band shortly.

I would not return to Mexico. When I factor in travel expenses, the price of a band in the U.S. is now comparable to what it would cost me to go to Mexico. As a self-pay patient, I am unable to afford a gastric bypass. This is multiple times the price of a band.

I am scheduled to see about putting on another band. The current concern is that there may be excessive scar tissue.

I will say that the band helped me grow. I believe a competent psychologist could assist me as well. I work from home, so I have access to food at all times, but I am constantly famished without the band. With the ensemble, I lacked appetite. There were times when I wished I had never obtained it. But now that I no longer possess the band, I wish I still had it. My expectation is that I will be able to get another one, even though I will have to pay for it out of pocket again.

Group Intolerance

On numerous occasions, I've been asked by patients, "Can I have the band removed after I lose all of my excess weight?" The response is "Only if you want to gain it back." Because of this, virtually all patients have AGBs for life. They eventually learn to eat differently and pay little heed to the band. In fact, the majority of patients dread losing their band.

Rarely, a patient will discover that they cannot tolerate the band. Despite having undergone exhaustive evaluations and counseling prior to surgery, they cannot tolerate the feeling of restriction once the band is in position. Before removing the band, I work closely with these patients to accomplish changes in their eating behavior. The majority of the time, the issue can be resolved. But if the patient persists, excision of the band may be the solution. While this is not technically a complication, it does represent a failure, which we undoubtedly try to avoid through careful pre-operative patient selection.

Dealing with a Crisis

G. Dick Miller, Psychologist

You sense you are in crisis. Something occurs. You didn't anticipate it. You could experience anxiety or discomfort. Now is the time to utilize your newly acquired rational thinking skills.

First, you must determine if the situation is truly a crisis. Another way to pose this is: How significant is the issue? Is a poultry bone lodged in my throat? Or am I humiliated because I'm using the restroom three times during a business lunch outing? Which is an emergency? I can also ask myself if I would dial 911 for this situation. Or is it just inconvenient? If the situation is truly dire, it would be in my best interest to seek professional assistance immediately.

Some of us were reared or educated to "awfulize," "horriblize," and "catastrophize" life's misfortunes. Although it is understandable that we were raised in this manner, it does not assist. We cannot resolve successive crises. If we elevate the inconvenient aspects of our existence into crisis after crisis, we will become exhausted.

Therefore, if it is not a crisis, it will be beneficial to my mental health and well-being not to make it one. I can call it what it is and then deal with it accordingly. By identifying what it is, I can determine its classification. Problems can fall into the following five categories: physical, social, emotional, financial, and spiritual.

The majority of individuals are familiar with the first four of these five categories. Using the restroom three times during lunch, for instance, is both a physical and social problem. What I refer to as spiritual issues are those that influence my spirit or essence. A member in my band's support group did not feel constrained by his band. Initially, he was optimistic and enthusiastic about his opportunities. However, as time passed, he received loads but felt no restriction. He observed other band patients lose weight while he himself did not. And he became disheartened.

He began to identify with the group members who spoke negatively about the band and what they couldn't consume. He began to miss support group and eventually ceased attending altogether. His issue was spiritual in nature. As his spirit, motivation, and confidence in himself declined, he bowed out. Spiritual problems are genuine, despite the fact that they are typically undervalued or even ignored.

Once you have determined the problem's classification, it is time to seek assistance. And the best location to find assistance with these issues is within your band's support group. So many individuals attempt to solve problems on their own rather than bringing them to a group of people who can comprehend their circumstance and provide insight. There is no justification for going it alone, as it is typically unsuccessful.

In our example of leaving the table multiple times during a business lunch to go to the restroom and vomit up, a support group might suggest ordering something that goes down easily, such as a bowl of soup, if you're going to talk. Or request that you examine your portion sizes. Or, you may discover that your band is too tight or too loose and requires a modification. (If the band is too loose, you can occasionally take larger nibbles, but you likely have not learned to consistently take small bites.)

If you are not a member of a band support group, you should join one. You will find that the assistance and solace you receive there will get you through a number of problems before you are compelled to label them a crisis. And it will improve your spirit.

Checklist: Crisis Management Procedures

Consider your reasoning.

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Is it truly an emergency? (Should I contact 911?) Or have I made it dreadful, horrifying, and catastrophic?

In an emergency, contact the appropriate professional for assistance.

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What category does it fall under if it is not a crisis: physical, social, emotional, pecuniary, or spiritual? (Problems may fall into multiple categories.)

Now that the issue has been identified, seek assistance. Band support organizations are ideal for this purpose.