By Dr. Göran Hellers, Stockholm, Sweden

Before (January, 1994)

After (January, 1999)

The first adjustable gastric band was implanted in 1985. Since then more than 30,000 bands have been implanted worldwide. Morbid obesity is associated with significant medical risks in terms of development of secondary diseases such as diabetes, hypertension, cardiac insufficiency etc. For some patients surgery is therefore an option in order to achieve sustainable weight reduction.

It is however important to point out that surgery is not a definite solution to the problem of morbid obesity but rather an emergency action in order to prevent the development of secondary conditions. Patients should not be lead to believe that all problems will be gone once they have undergone surgery.

In the adjustable gastric banding method a band is applied around the stomach about 20 mm below the gastro-esophageal junction. On the inner lining of the band there is a longitudinal balloon (like a bicycle tire). This balloon is through a small tube attached to a subcutaneous port. The band is left empty at time of surgery but is thereafter gradually filled with fluid by injection through the subcutaneous port. It is thus possible to vary the opening in the stomach after surgery.

In most cases the band is applied through open surgery, but we have recently also started to develop laparoscopic application of this band. The total experience in Sweden is now about 1,500 cases.  The first patient was operated in 1985 and the method has since then developed gradually. Today we can expect that approximately 75% of the patients will loose 75% or more of their overweight within 18 months after surgery. Recent results indicate that weight loss is sustainable since most patients have the same weight at four years as at two years after surgery.

About 10% of the patients have various forms of problems or complications. These complications are usually minor. The rate of major complications is low. There have been no deaths in the Swedish series of patients.

The balloon band system can be regarded as putting a straight-jacket on the stomach. The band induces an early feeling of satiety and thereby decreases food intake. Our method as well as other methods for obesity surgery does not however change the basic patient behavior pattern. If the band is removed the weight will quickly increase to what it was before surgery. This means that the operation is not a definite solution to the patient eating pattern or the problem of morbid obesity. It however induces sustainable weight loss and therefore it leads to a healthier life with less risks for obesity related secondary diseases.

TYPES OF ADJUSTABLE GASTRIC BANDS

Today, there are three types of bands that compete for the market of adjustable gastric banding. Our surgeons use three different brands of bands, the Lapband, the Swedish band and The Midband.

It can be interesting for future patients to know the history of the development of the bands available on the world market:

Professor Dag Hallberg was the main inventor of the concept of AGB. In1984 he started cooperation with the Swedish silicone manufacturer Atos AB and a Swedish medical equipment company, Astra Meditec AB. Hallberg applied for a patent only in Sweden, Norway and Denmark. He received the patent on March 14, 1985. The Hallberg (or Swedish Adjustable) band has been sold to Switzerland and is now marketed by the Swiss company Obtech AG. Kuzmak´s band is marketed by the American company Bio-Enteric. Finally, the new French band is marketed by the Swedish company Lowate AB.

Soon after Hallberg, Dr Lubomir Kuzmak in the US got the same idea. He applied for a patent only in the US and received his patent August 25, 1985. The shape of the two bands is however very different. In the case of Hallberg the balloon is covering the whole inner lining of the band. Kuzmak´s band, according to the patent application, has a balloon only covering a small portion of the inner lining. Hallberg´s band has a wide range of adjustability while the opening in the Kuzmak band could only be varied a few mm. Later Kuzmak´s band has been redesigned and the diameter can now be varied up to about 7-8 mm.

The patent for the Swedish/Swiss band was valid only in Scandinavia and the patent for the American band only in the US. In the rest of the world the market was free.

Later another band has been developed in France. This band is a little shorter than the Hallberg band and with a somewhat bigger balloon. The reason for this is to make the system softer and serve as a cushion between the gastric wall and the band. The balloon can take up to 10 mm but will in clinical practice never be filled with more than 4-5 ml. At this level the inner gastric diameter will be about 12 mm. This construction means that the system will always be a low-pressure system that should decrease the risk for erosion/migration. This band is now fully approved in Europe and received the European CE certificate in January of 1999.

Other bands have now been developed, and today there are at least half a dozen bands available on the world market. The Midband, manufactured by Médical Innovation Développement in France, is extremely flexible making it easy to fit. It was designed by Dr. Frering in Lyon, after his extensive experience with other bands. It has no sharp edges or
irregularities preserving the gastric wall intact, even in event of rubbing. It is opaque to X rays, making it easy to locate and adjust.

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INDICATIONS FOR SURGERY

A body mass index (BMI) of more than 40 kg/m² for at least five years. A normal BMI is between 20 and 25. If there are obesity related complicating diseases such as arthrosis, diabetes, hypertension etc. the lower acceptable limit for men is > 36 kg/m² and for women >38 kg/m².  

An upper age limit of 55 or maybe up to 60 years depending on general health.  

An acceptable surgical risk.  

Repeated unsuccessful weight reduction attempts under competent medical supervision. 

Absence of endocrine etiology, i.e. thyroid malfunction.  

Mental stability which implies no alcohol or drug abuse and no mental illnesses. 

The patient should also understand that surgery is not a quick fix. It is always associated with at least some risk. There is also no guarantee for a successful outcome in the individual case.  

PERIOPERATIVE MANAGEMENT

Preoperative evaluation is carried out 3 - 4 days before admission. Same day admission is standard.  

Preoperative evaluation includes basic clinical chemistry, EKG and a lung X-ray. Other investigations are carried out if deemed necessary. 

Intravenous antibiotics for prevention against postoperative infection and anticoagulants for prevention of postoperative thrombosis are standard medications.  

Mobilization of the patient is started immediately, i.e. a few hours after surgery. Oral intake is started immediately (about 250 ml on the day of surgery) and quickly increased to 1000 ml on the second day, 1500 on the 3rd day and thereafter free liquids. The patient is normally discharged after 2 days. In the case of laparoscopic surgery some patients may even be discharged the day after surgery. 

The normal period of postoperative sick leave is three to four weeks depending on type of work. 

During the postoperative phase the patient should have liquid multivitamin supplementation (in particular vitamin B) and liquid protein supplementation (i.e. Ensure). Peroral pain relief is often necessary for 4-7 days. Tylenol tablets or any similar substance may be used. The tablets should be split in two or three pieces before taken. 

The abdomen is supported by an elastic girdle, which is usually kept for 3-4 weeks. This girdle will decrease postoperative pain and thereby help prevent the development of incisional hernias.

THE OPERATION

The aim of the operation is to give the stomach the shape of a time-glass. There should be a very small upper gastric pouch with a new relatively narrow opening to the stomach below. The stomach as such is not changed or operated upon and it is always possible to restore the normal anatomy, if this should be necessary. 

The new upper gastric pouch has in the immediate postoperative period a very small volume (5 - 10 ml). The emptying in the immediate postoperative phase takes 20 - 40 minutes. With time this small pouch becomes somewhat bigger, but it must not become significantly bigger. In such a case the whole aim of the operation will be lost. 

The body absorbs all food taken in in the same way as before the operation. The digestive functions are not changed by the operation. Weight reduction is achieved through reduced food intake. The food intake is reduced because of the small pouch, which induces an early feeling of satiety after intake. 

Oral intake is started on the afternoon of the operation. The fluid should be taken in very small amounts at a time. If a big sip is taken quickly this usually causes uncomfortable abdominal cramps and associated pain. A good way to ensure that small amounts are taken at a time is to take the fluid by using a tea spoon. The intake of liquids is then increased over the next days and it is usually possible for the patient to take his/her whole requirement of liquids (about 2 - 2,5 liters) by mouth within 2-3 days. When this is achieved, the patient can be discharged. 

CONVALESCENCE

The operation is a first step in a major life adjustment. During the convalescence the wound will heal and the patient will have to learn a new behavior. The operation helps in adjusting the eating pattern.  

It is however also important to change the behavior with respect to physical exercise. The first month after the discharge only liquids are allowed. The reason for this is that the body must get time to heal and develop adhesions so that the band becomes fixed in the right place. Previous experience has shown that patients who have eaten solid food too early runs a risk of dislocating the band and thus develop enlargement of the new upper gastric pouch. 

Following the month of liquid diet, the patient is advised to eat mashed food, and thereafter use small portions of normal food.

AFTER THE CONVALESCENCE

Since the patient is eating only small amounts of food, it is important to choose good food, containing nutrients of high quality. The eating pattern should be regular with three meals a day and sometimes small meals in between. Eating of several small meals in between the main meals should be avoided. It is important to chew the food extremely well. Every bit should be chewed 15-20 times before swallowing. It is also important to let the meal take time, if necessary 30 - 45 minutes.  

Patients should not drink with the meal. They should try to eat the meal as dry as possible. This is in order to keep the food in the upper pouch for a longer time and thereby achieving a better feeling of satiety. It also reduces the risk for the food to get stuck in the new narrow opening. This can induce pain and vomiting. Fluid should instead be taken 10 or 15 minutes before the meal. Suitable fluids are water, tea, coffee, juice etc. Large amounts of sweet and calorie rich fluids should absolutely be avoided. Anything that can be taken in by a straw after the operation can also be taken in without limits through the new opening. It is possible to take in significant quantities of calories if these instructions are not observed. In such a case patients will not loose less weight.

VOMITING

Most patients will once or twice feel pain or vomit after intake of food. This is in most cases caused by eating too much and too quick. If eating is slow and calm, patients will learn to listen to the signals from the stomach. Eating should be abandoned if the patient feels nauseated, have pain or vomits. Regular vomiting is a sign of warning. This can either be caused by wrong eating behavior or be caused by the outflow of the gastric pouch becoming too narrow. This means that the balloon may need to be adjusted. Regular vomiting should be discussed with the physician in charge and corrected.  

ALCOHOL

Alcohol in any form is rich in calories and easy to take. Large intake of alcohol is therefore contrary to the aim of the operation. A glass of wine or something similar at special occasions is however not wrong. Many patients however feel that they cannot tolerate alcohol after the operation. This may be caused by the fact that alcohol reduces the blood sugar level. This level may, as a result of the operation, already be low and further reduction is therefore for some patients difficult to tolerate. It is therefore advisable to be careful with alcohol-containing beverages after surgery.

VITAMINS

During the phase of rapid weight reduction (6 - 12 months after surgery) supplements with vitamins are advisable. Particularly the various vitamin B´s are sometimes ingested in insufficient quantities. Liquid vitamin mixture containing the usual vitamins and in particular vitamin B is therefore advisable during at least the first 6 months after surgery.

PREGNANCY

The period after surgery until the weight is stabilized has to be regarded as a period of relative starvation. It is not advisable to become pregnant during starvation, because the child may suffer from this. When weight loss is completed there is no contraindication to pregnancy. 

MEDICATION

All tablets must be divided into small pieces or crushed before they are taken in together with water. It is very common that changes in medication for hypertension, diabetes, asthma or other diseases may be necessary during the period of rapid weight reduction. Patients should consult their doctors concerning this.

CONSTIPATION

Many patients feel constipated after surgery. This is mainly caused by the fact that the reduced food intake leads to less feces and it is thus normal with fewer bowel movements. If laxatives become necessary, it is advisable to abstain from so called bulking agents and instead use liquid laxatives, such as lactulose.

HAIR LOSS

Many patients are suffering from increased hair loss during the first six months after surgery. This is also caused by the relative starvation. This however never leads to baldness and normal hair growth will eventually return.

DOCTOR'S VISITS

After surgery the patient must undergo regular check-ups as an out-patient. In the beginning this will be carried out monthly but later the intervals between visits will increase. When the weight has stabilized, patients will be called for annual check-ups. The reason for these check-ups is to avoid developing various states of deficiency, in particular anemia. This may sometimes occur, although not so frequently after this type of surgery. 

PHYSICAL ACTIVITY

It is not only important to change eating habits. It is equally important to change the physical activity level. Patients are generally recommended to start slowly. The best is to start walking regularly, initially approximately half an hour per day and then gradually increase the activity level.

FOOD INTAKE

During the period of hospital stay

It is important to be mobilized out of bed as soon as possible in order to avoid thrombosis and pneumonia. Already during the evening of the day of operation the patient should stand up and walk around a little bit. The physiotherapist will instruct about the best way to get in and out of bed. Pulmonary complications are best avoided by blowing through a tube into a water bottle every hour. After surgery patients will also have a girdle around the stomach. This is there in order to facilitate coughing and breathing and also to prevent the development of abdominal hernia. This should be in place for four weeks after surgery.

Fluid intake is started on the evening of the day of surgery. One glass of water (250 ml) should be taken the first day. This should be taken in small amounts at a time, i.e. with a tea spoon every 5-10 minutes. The remainder of the fluid requirements will be given by intravenous infusion. The oral intake will be rapidly increased during the coming postoperative days. The liquid intake is therefore increased and the patient should be on a total liquid diet without intravenous supplementation from day 2 or occasionally day 3.

The advises regarding intake is thereafter subdivided into four periods.

Period 1

Liquid diet for 4 weeks. On the average 100 ml should be taken every hour in small amounts at a time. The type of fluid should be varied and contain i.e. sour milk, yogurt or gruel, tea or coffee, fruit juice or vegetable juice, warm trickled soup or broth. There should also be some kind of dietary supplement drink including the common nutrients. It is important to spread out the intake over the whole day and take small amounts at a time.

Period 2

Purée diet for 2 weeks. Purée should be taken in small portions at a time. Soup and dietary supplements should be continued. In most food stores it is possible to buy child food cans for children of 5 - 8 months of age. These are the best in order to have the correct consistency of the food. Patients should not drink with the meal. Drinking should be done between meals. Meals can be adjusted to the working situation but it is important that the approximate amounts of food are observed. The total amount of liquid must be at least 1500 ml. This should be taken at regular interval 150-200 ml at a time. The type should be varied and include tea or coffee, sour milk or yogurt, fruit or vegetable juices etc. The total amount of purée food should be about 500g. The purée food should contain common nutrients such as meat or fish. This should also be divided and taken 100-150g at a time. Eating must always be slow with small amounts taken at a time.

Period 3

Small portions of normal diet for two weeks. Intake of food with more normal consistency can now be started. The portions should however always be small and drinking with the meal is not allowed. Drinking should be done between meals. It is very important to eat slowly and to chew the food thoroughly. When sour milk, milk or yogurt is used, this should now be the low fat variants of these products. The total daily amount of liquids should be at least 1500 ml and the total amount of solids about 500g. The solid food may now be taken at normal eating hours. It is however important that enough time is allowed so that eating can be slow.

Period 4

Patients can now start to make up their own menus. It is however still important to eat often, little at a time and to chew the food thoroughly. Drinking is allowed only between meals and only in form of sugar free alternatives. Food should be based on boiled or mashed vegetables. Fish or low fat meat should be used and boiled rather than fried. Other products should also be of low fat content (light milk, light cheese with 17% or lower fat content, light ice-cream etc.).

FOOD RESTRICTIONS

There are certain food stuffs that are difficult to tolerate and which therefore should be avoided. These are usually food stuffs that may easily get stuck in the opening of the stomach and therefore are associated with a significant risk of causing obstruction and thereby vomiting and fluid depletion.

Fibrous food stuffs

Asparagus - trickle the soup
Pineapple - press for juice
Rhubarbs - trickle the soup
Broccoli - use only the buds
Oranges and dried fruits may not be used at all because of the great risk for these to swell and get stuck in the new opening of the stomach.

Sticky food stuffs

Coconut
Chips
Popcorn
White, soft bread

Difficult to digest

Nuts
Almonds
Peanuts

In addition to these it is for most patients very difficult and in most cases impossible to take whole meat. Ground beef is tolerated by some patients if thoroughly chewed. It is therefore advisable to abstain from meat intake.

LONG-TERM COMPLICATIONS

Adjustable gastric banding is well tolerated by most patients. Complication rates are low but this does not mean that complications are non-existent. The following is list of the complications that have been seen following this operation; 

Infection

There has been a few cases of deep infection in the abdomen leading to removal of the band. There has also been some infections of the port system leading to removal of the port. These events must be regarded as failures of the operation. Sterility during injection is obviously of great importance in order to minimize or avoid this complication.

Band problems

Three bands broke early in our series. Since then the band has been reinforced with additional dacron mesh and this complication has since then not occurred. In five other cases the balloon has broken and these patients immediately started to gain weight. The balloon has also lately been reinforced in order to withstand increased pressure. All these cases had to be reoperated. Although we have now improved the implant it must be pointed out that a definite guarantee against technical problems like these can never be given.

Band migration

There are two types of bands that we use. There is a Swedish band (sold by Obtech AG) and a French band (sold by Lowate AB). Migration occurs when the band and balloon migrates through the stomach wall into the stomach lumen. These cases are outright failures and these patients have quickly regained their preoperative weight. This has so far occurred in about 3% of the cases when the Swedish band has been used. With the French band there are no migrations at this point in time. The French band has however been used much shorter time and since migration usually does not occur until 18-24 months after surgery it is too early to say which band will be the better in this respect. Patients who have their bands filled quickly and with high total volumes have an increased risk of migration. Filling must be slow and gradual. Total volumes over 9 ml should be avoided with the Swedish band and 5 ml with the French band. If these guidelines are observed the frequency of this type of complication will decrease.

Port problems

There has been port problems in about 4% of the cases. There has been two types of problems. The first is dislocation of the port. It may move around, turn up-side-down and can in this position not be injected. It is thus necessary to adjust it. This is a simple operation in local anesthesia but nevertheless a nuisance to the patient. The second problem is perforation of the connecting tube close to the port. Some patients have extra fat over the chest and it is therefore sometimes difficult to hit the ”bulls eye” with the needle and the tube may be accidentally perforated. This leads to loss of fluid, widening of the opening and subsequent weight gain. This is also corrected in local anesthesia. The port is brought to the surface, a bit of the tube including the hole is cut off, and the remaining tube is reattached to the port and finally the port returned into position. The design of the system has because of this problem been changed. The distal 2 cm of the tube is now covered with a protective sleeve in order to avoid this problem.

REOPERATION

As stated above some patients will need reoperation. The patient must however understand that the probability of reoperation is an integral part of the overall management of morbid obesity. A reoperation should be considered as a technical measure that is sometimes necessary. Even if the overall reoperation rate following adjustable gastric banding is low the need for reoperation must not be considered as a failure of the method. The problems can however usually be corrected and the patient is after that usually back on track.

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