The adjustable gastric band (AGB) is a sort of weight-loss surgery, but it doesn't exactly fit into the category of standard bariatric surgery, as we discovered in the previous chapter when we examined the different types of bariatric surgery. This chapter aims to provide information regarding the placement and operation of the AGB as a tool.
Overview of the Role of the AGB
The AGB's fundamental premise is actually fairly straightforward. The band restricts how much food you can eat by acting like a tourniquet around the top section of the stomach. It divides the stomach artificially into a smaller upper pouch and a larger bottom pouch. Only the speed that the band will allow allows food to enter the lower pouch. (Please refer to the figure on the page after this.)
The upper pouch immediately fills up and slowly empties. Without running the danger of stapling, diverting, or altering the stomach or any other section of the digestive tract, restriction of food intake is created. The AGB is now the safest surgical technique for the therapy of obesity because it does not necessitate rearranging the digestive system.
One of the ways the AGB functions to encourage weight loss is by regulating how much food the stomach pouch can contain. The band's ability to decrease hunger is arguably its most impressive impact. Hunger is the primary cause of diet failure, as everyone who has ever tried one can attest. The space above the band can be filled with food in a very brief amount of time.
entirely, yet patients claim that they still feel as satisfied as if they had eaten a substantial meal. After a meal, food typically remains in the upper pouch for several hours, causing satiety.
Additionally, even when they haven't eaten anything, patients with bands frequently claim that they aren't actually hungry. This seemingly miraculous effect's physiologic causes are not fully understood. However, it appears likely that any food or liquid in the upper pouch triggers the release of hormones or nerve impulses from the stomach that turn off the brain's hunger center. Because of this, some individuals relish the absence of hunger for extended periods of time.
The band restricts how much food may be consumed by acting like an adjustable tourniquet around the stomach.
The trick to making the band function is imposing the proper level of restriction. The band helps people lose weight when it is fitted correctly, but it also ensures that enough food and liquids reach the rest of the digestive system. When a band is excessively slack, it
won't provide enough limitation to be useful. If it is overly tight, it will severely impede the passage of food and liquids through the stomach, which could result in extreme dehydration or malnutrition.
When the band is appropriately tightened, the gap between the two stomach halves is quite small, resembling an hourglass. Saline solution is injected into a tiny reservoir that is positioned beneath the skin and connected to the band by a length of tubing to inflate the band to the right level of restriction. Removing part or all of the saline may also help to relax the band. Although it might seem simple, properly adjusting the band can be difficult, and this book has a full chapter devoted to the procedure.
Surgery to Implant the AGB
Operative laparoscopy, a procedure, is generally always used to accomplish the AGB placement procedure. Because there isn't a significant incision, as is typical in traditional surgery, this kind of surgery is occasionally referred to as minimally invasive.
Less pain, a quicker recovery, and less obvious scarring are benefits of laparoscopy. Patients who are obese, who are known to have higher surgical risks, can benefit the most from it. Patients experience less trauma, resulting in a decrease in their need for pain medication. They can immediately resume routine activities once they are up and moving around more quickly.
A tiny tube called a cannula is inserted into the abdominal cavity during laparoscopic surgery through the skin and muscle wall. After that, carbon dioxide gas is inflated inside the cavity, much like a balloon. The surgeon can work between the internal organs and the abdominal wall thanks to the pressure of the gas.
The term "laparoscope" refers to a long, narrow telescope that is connected to a small video camera and a high-intensity light source. When the laparoscope is put into the patient, the camera is attached to a high-resolution video monitor so that
the surgeon a remarkable view of the interior organs in the belly.
Additional cannulas are introduced through the abdomen wall to act as conduits for the surgeon's specialized instruments during the procedure. Every action is visible to the surgeon and the rest of the team on video monitors.
The liver must be physically moved out of the stomach to reveal the area of the upper stomach. In severely obese people, the liver is frequently fairly big and rather inflexible. This may present a significant challenge when attempting to maneuver around the top section of the stomach. A large "fatty liver" can, in rare circumstances, make it extremely difficult to carry out the treatment successfully. My patients are put on a three-week preoperative low-fat, low-carbohydrate diet to prevent this scenario and make the treatment safer and simpler. This pre-op diet can pay large benefits because the liver typically decreases dramatically in only a short period of time (I explain the details of the diet in Chapter 8: What to Expect before Surgery on pages 99–100).
Prior to inserting the band, the upper stomach region is first dissected during the procedure. The procedure can take much longer depending on how much fat is present around the lower esophagus and upper stomach, but a competent surgeon can usually complete it in only a few minutes. The dissection of men is typically more challenging than that of women. Compared to obese women, who typically carry more of their fat under the skin, obese men tend to have more fat around the stomach and other places inside the belly. A few ounces of food can fit in an upper stomach pouch that is formed when the band is placed correctly.
The AGB must be positioned correctly around the stomach in order to be effective. The pouch will be too small to hold enough food to provide adequate nourishment if it is positioned too high. The band may be wrapped around the esophagus, which could cause a variety of issues, such as difficulty swallowing, blockage of the swallowing tube, or even esophageal damage.
The pouch will be too large if the band is positioned too low to be useful for weight loss. As a result, the band is useless for aiding the patient's weight loss. Additionally, heartburn is a typical symptom of a low band.
The two most well-known bands are mostly due to the fact that they were the first to be made available to the public, but as the band becomes more well-known, there will undoubtedly be many different iterations. The most common band has a circumference of 10 cm and can store 4 cubic centimeters of saline. Another common band has a diameter of 11 centimeters and can store 10 cubic centimeters of salt.
Most of the time, it is simple to wrap the smaller-size band around the stomach and the surrounding fat. However, if there is an excessive amount of fatty tissue inside the band, it can lead to early occlusion, meaning that the band is so tight that not even liquids can pass through. By trimming some of the fat before the band is put on, this issue can be avoided. But getting rid of fat can be challenging and dangerous for the stomach. Using a bigger band, one made especially to prevent the possibility of early occlusion, is a preferable option.
The surgeon initially fills the chosen band with saline to make sure it won't leak before placing it. It is then deflated and placed through one of the cannulas into the ab domen. To move the band tubing, a device is inserted behind the stomach. After that, a locking mechanism snaps the band shut around the stomach as the tubing is progressively drawn through an aperture in the band's end. There is a small chance that the stomach or nearby organs could get hurt during this stage.
The surgeon's laparoscopic experience and the quantity of fat surrounding the stomach both have a significant role in surgical risk. Since the surgeon can't see very well behind the stomach, a damage to the rear wall may be difficult to find. If a perforation develops there, the results could be disastrous, especially if it is not detected right away. A serious, potentially fatal infection will almost invariably result from the leakage of stomach contents into the abdomen. Fortunately, compared to other operations like gastric bypass, this is rare with the AGB.
Undiagnosed hiatal hernias might also make it more difficult to properly place the band. This condition is really extremely common and is frequently accompanied by heartburn. It is known as a hiatal hernia when a portion of the stomach pushes up through the muscles of the diaphragm. Before continuing with the band implantation, a minor hiatal hernia should be fixed. The band might not be a good option if the hernia is more than 1.5 inches in size. This circumstance is linked to a higher frequency of postoperative complications, including band displacement and potential hernia recurrence. Prior to surgery, it is a good idea to perform some sort of testing to rule out a significant hiatal hernia in individuals who have complaints of heartburn, chest pain, or regurgitation of meals.
A band around the stomach is comparable to a ring around a water-filled balloon. The stomach is an extremely malleable, sac-like organ that has the ability to drastically alter shape over time. The AGB will probably slide up or down as the stomach moves if it is not fixed in some way. The surgeon pulls a section of the stomach wall up over the band and stitches it above the band to keep the band where it needs to be. The plan is to enclose the band inside the stomach wall's passage. This secures the band in a manner similar to how a belt loop secures a belt. Only a small portion of bands make it out of this tunnel and begin to slide up or, more frequently, down on the stomach. This is known as band slippage, and it will be discussed in more detail in a later chapter of this book.
The end of the band tubing is brought out of the abdominal cavity through one of the cannula ports once the band has been firmly fastened in place. The "port" is a reservoir composed of hard plastic with a titanium steel bottom that receives the tubing once it has been tunneled under the skin. A specific silicon rubber plug on the front of the port can be opened by inserting a specialist needle through the skin. This makes it possible to inject saline solution to change the band's tightness. As the specifically made needle is removed, the silicon stopper reseals.
The port can be positioned virtually anywhere along the abdominal wall, however it is often positioned on the upper left side of the abdomen. It only has to be
accessible by puncturing the skin with a needle. After the port has been installed, a layer of fat is placed over it. The harder it is to feel the port through the skin, the thicker the fatty layer is. Due to the fact that the fatty layer is typically thinner there, some surgeons choose to place the port higher up, on the breastbone. While the port is more accessible with a needle because of its placement, there may be a visible swelling and bulge between the breasts as a result. The patient's weight loss will make this even more clear. Because of this, most surgeons favor positioning the port on the side of the abdomen.
Following the port's attachment to the muscle, dissolvable sutures are used to seal each of the minor skin incisions. Before the patient leaves the operating room, tiny dressings are applied to each incision site. Even if the procedure is now complete, for the patient it is just the beginning because they now have a new weapon in the fight against obesity.
The AGB: A Surgeon's Perspective
As a surgeon, I'm used to treating patients directly to solve a variety of issues. Because conditions like appendicitis and hernias, which may be treated surgically, are "fixable," many physicians are drawn to a career in surgery.
Making the diagnosis, walking the patient through the procedure, and carrying out the operation are normally the surgeon's responsibilities. Once the patient has recovered from surgery (that is, the fire is out), the surgeon's job is finished. For many acute illnesses or disorders, the surgeon serves as a healthcare "firefighter."
In stark contrast to many chronic medical problems that need ongoing management, the surgeon's work is very different. Even when it is surgically corrected, obesity is still a long-term issue. Today's society is continually told there is a "quick-fix" for just about everything, from heartburn and insomnia to foul breath and wrinkled skin. Of course, we desire such a remedy for obesity. We frequently hear promises of quick weight loss, so it might be challenging to think otherwise.
It was only natural for me to conceive of the band operation in the same manner I thought of other surgical operations when I initially started using the AGB to treat obese patients. I thought that the treatment alone would result in successful weight loss, even though I was aware that there were other concerns that would need to be dealt with. Clearly, that was an incorrect assumption. I realized patients required a program to support the procedure as I observed them struggle to adopt the lifestyle modifications I advised.
The hardest thing for my staff and I to do is to convince our patients that the AGB is not a panacea for their weight issues. Many patients have the misconception that receiving a band means they won't ever have to worry about their weight again when they come to see us. Simply said, this is untrue. It is a tool, the AGB. The surgical treatment does not automatically result in weight loss; it only installs that instrument.
Dan's Tale
I had always been overweight. My maximum weight was 355. I weighed 323 when I got my band in 2003; I was 340 in my before photo. Four years later, I consider the changes in my physique in terms of my life changes rather than merely weight loss. My pants, which were formerly a size 56, are now a 38 or 40. My clothing, which used to be 3X or 4X, are now XL. I do my shopping elsewhere, not simply at the "fat guys" store. Even though I just celebrated my 64th birthday, I am able to fit in restaurant booths, exercise without difficulty, and carry out a variety of other things that I was unable to accomplish when I weighed an additional 140 pounds.
As the network information coordinator for a university library, I also serve as the leader of the SmartBandsters Yahoo group, which provides support for banded individuals. Thousands of people have posted their queries and worries, as I have observed. No matter what kind of weight-loss surgery they have, I find that a lot of patients believe they will be magically healed. That is untrue. Peeling back the layers of an onion is the greatest comparison I can think of for life with the band. There is usually a deeper layer, particularly in cases where psychological eating has been involved.
My wife and I both have alcoholism in recovery. We've both previously been married. I've already dealt with a lot of my problems, which is one benefit of my 12-step work. Being banded has taught me that compulsive eating is similar to drinking. The term HALT, which stands for "hungry, angry, lonely, or tired," describes the conditions that typically lead the average drinker to turn to alcohol. If I find myself in one of those four states, I know to keep an eye on myself. There is always food. Food is also more difficult to deal with because it is socially acceptable to eat whereas drinking and using drugs are not.
One Scotch is too many and 100 is not enough, according to an AA proverb. With other foods, it's the same for me. There was a commercial from Frito Lay that claimed, "Betcha can't eat just one." I am aware that I cannot eat just one M&M or one potato chip. With drugs or alcohol, though, I can just avoid them. I have a food addiction. Three or more times a day, I have to battle that devil. I'm eating in front of other people who can handle food in a more "normal" fashion, which adds to the difficulty. They won't suffer from having just one.
Even while the band limits what I may eat, one thing it won't prevent me from doing is "grazing," as long as I'm eating three or four little meals a day. But if I spend the entire day at a buffet and I just keep nibbling for a few hours, I'll eat enough food to last me many days. So I try to stay away from circumstances where I can just graze all day.
I contend that there are biological factors at play with weight. For instance, some of us have problems with the chemistry of our brains. There is no one problem that causes obesity. You have to deal with both the physical and the rest because it has so many facets.
People are unaware that it is possible to regain the weight lost with the band. Because the band allows you more time to change your habit, I think that's more common with the bypass than the band. Additionally, the bypass cannot be adjusted but the band can. It could be a concern if someone relies heavily on the restriction that comes with the bypass because there's a good chance they will eventually lose the restriction.
People should, in my opinion, join a band support group in advance. However, many doctors who undertake gastric bypass surgery also perform band surgery. Some clinics make an effort to group all of the patients together in a situation like that. I believe that is incorrect. It can be demotivating for someone with a band who plans to lose weight more gradually, at the pace of one or two pounds per week, to see how quickly bypass people lose at first. Additionally, there are other difficulties specific to band members that might not be discussed or overlooked in a mixed group.
One of the problems specific to band members is something some refer to as PB-ing, or productive burping. Considering that it is coming from above your band, it is more akin to baby spit-up. Whatever you want to call it, I discovered I had this issue up until I discovered how to properly chew. The accepted practice is to take 20 chews, setting the fork down in between each bite. Many people are accustomed to quickly shoveling food into their mouths, whether they are driving or watching television. I was watching a football game when I realized at halftime that I had consumed the entire large bag of chips before getting my band. I initially believed the dog had gotten into the chips, but then I realized we no longer had a dog. I've discovered mindful eating is more effective. When I eat, I consider what I'm eating and monitor my hunger levels with each bite.
Because I was constantly eating, I also became aware that I had never physically been hungry. I had also never learned to distinguish between emotional and bodily hunger. or distinguishing thirst from hunger. Some people, I've discovered, eat when they're thirsty. It takes time for band people to understand those distinctions.
Some of the band's "rules" have been changed to fit my own lifestyle. As an illustration, I drink water up until the beginning of a meal. I then tell the waiter or server that I don't need a refill and put the water glass away. I reason that if food is taken in first, the water will just pass right through the pouch. But as soon as I start eating, I stop drinking.
I also employ other strategies. As an illustration, when they bring the dinner in a restaurant, I ask them to also bring the carry-out box. I split my meal into smaller portions before I begin to eat, and
Place the remainder in the takeout box. I never brought a takeout box home from a restaurant when I wasn't banded. We had no money, and my parents were destitute because of the Depression. Because we were instructed to clean our plates, I stayed at the table until I had, even if it meant consuming the loathed vegetable eggplant. I was able to clear my plate thanks to that instruction. So now I just watch how much food I eat before I start.
I frequently observe that band members dislike working out. Exercise, in my opinion, is yet another crucial adjustment you must make. I used to lift weights even when I weighed 355 pounds, but I didn't jog as much as I do today.
It would be wise for band members to decide in advance if they want to disclose their band status to others and to whom. You cannot untell once you have spoken. When I told one of my sisters, who oversees medical records at a large hospital, that I wanted a band, she reamed me. I provided her several references and recommended we chat again once she had looked it over. I told her, "You know me, I do research for a living. I've researched the band very carefully." After a few days, she called and apologized.
I have only received three fills. I simply haven't required more. What I've noticed is that band members frequently discuss the band's size and fill content. I simply avoid discussing it because I believe it to be unimportant. Fills are either too huge, too small, or just perfect, like Goldilocks and the Three Bears. Additionally, each person's response to the fill will vary.
I also underwent a belly tuck for cosmetic reasons because the extra skin around my middle was bugging me. Given that I have extra skin on my arms, chest, and inner thighs, I thought of doing more. But when I asked my wife, she seemed unconcerned. I made the decision to forgo more plastic surgery because I don't find it bothersome either.
The major issue is changing behavior. Working with band patients online, I frequently observe it. There will always be those who refuse to change because they insist on carrying on with how they've always done things. If they continue, the pouch may enlarge, the band may deteriorate, and several other problems may occur. There are always a few people whose band has been seized.
out, nearly always for behavioral reasons. And a handful when the band just doesn't agree with their stomach. Many people who previously experienced reflux report that it has disappeared after getting a band, whereas others who had never previously experienced reflux report experiencing it. There never appears to be a single, clear solution.
Although I am an instructor, I do not consider myself to be a missionary for the band. I'm happy to educate others if that will benefit them in some way.