Guy Slater FRCS
Specialist Upper GI,
Laparoscopic and Bariatric Surgeon
Laparoscopic and Bariatric Surgeon
Laparoscopic adjustable gastric band surgery (LAGB) is the safest and least invasive operation, that produces long-term permanent weight loss. Streamline Surgical uses the LAP-BAND AP System manufactured by Allergan, which is the World's most widely used and researched laparoscopic adjustable gastric band system.
Laparoscopic surgery, sometimes known as keyhole surgery, through 4 small incisions, is used to place the lap band around the top of the stomach. It is normally a day-case procedure, although patients from further afield may wish to stay overnight. Most patients are back to normal in a week.
The LAGB has an inflatable reservoir on its inner aspect that encircles the upper stomach. Saline can be added to this inflatable reservoir, via an access port placed under the skin of the patient's abdominal wall. Small amounts of saline are added, at regular out-patient appointments, until the LAP BAND is correctly adjusted. At this point, portion size and appetite will be better controlled, with weight loss following.
Weight loss can be as good as or better than the other operations, but patients need to work with the LAGB to achieve the best results. Unlike the other surgical options, LAGB is fully reversible, although this is not advised as weight regain will occur.
No one knows for sure how the LAGB works. The best research has been conducted by Professor Paul O’Brien and his team from Monash University, Melbourne, Australia. Professor O’Brien believes the LAGB works by controlling appetite and inducing early satiety.
There is no doubt that when the LAGB is correctly adjusted, patients report that they are less hungry; 24 hours a day they are less interested in food. In my experience, most severely overweight people are always hungry and driven to eat. Patients often tell me that they go to bed thinking about food, wake up thinking about food and spend all day thinking about food. It’s no surprise that diets don’t work for them. For most patients, it is a release not to be constantly driven to eat.
The second effect of LAGB is to control portion size. This is probably more of a psychological than physical effect. When well adjusted, the LAGB makes the patient slow down when they eat, take smaller mouthfuls and chew very well. By slowing down, the patient’s brain is fooled into thinking, that they are full much earlier than usual.
These effects will only occur if the LAP BAND is in a good position, is optimally adjusted and the patient eats foods that work well with the lap band. It takes time and good training for surgeons to learn how to position a band well, in all patients. Initially patients need frequent, small adjustments to reach the “sweet spot”, when their appetite is well controlled. Good aftercare is essential to keep the lap band optimally adjusted. From the patient’s perspective the key to success is choosing good quality food that works well with the LAGB, avoiding liquid calories. Professor O’Brien has published the eight golden rules for success with the LAGB, which we’ve found to be an excellent guide for patients.
Research including many thousands of patients, has shown that on average, patients undergoing LAGB will lose 50% of their excess weight. Professor O’Brien has published much better than average results, with patients losing 70% of their excess weight at three years, and maintaing a 60% excess weight loss eight years after surgery. The reason for his success is the excellent aftercare that his practice provides and Streamline Surgical emulates. We are now seeing the same level of success too.
As an example, a typical lady who is 5’6” tall and weighs nearly 20 stone (BMI 45 kg/m2), is 9 stone over her ideal weight. On average with laparoscopic adjustable gastric banding this lady would lose 4.5 stone and have a long-term weight of 15 stone. With good aftercare and by following Professor’s O’Brien’s eight golden rules, she should achieve a better weight loss, probably losing just over six stone at three years and having a long-term weight of 14 stone. Some patients will lose more weight still. In practice, weight loss after bariatric surgery is affected by many patient factors, including age, activity level, dietary discipline and basal metabolic rate. With good weight loss many of the medical consequences of obesity can be reversed or improved. There is good evidence that weight loss with LAGB, can improve type II diabetes, blood pressure, obstructive sleep apnoea and gastro-oesophageal reflux.
Following surgery, patients are seen regularly by the members of the bariatric service. The first appointment will be two to four weeks after surgery and will be with a surgeon or a specialist nurse. At this time the LAGB will be adjusted as discussed below. If there are no surgical concerns and we are happy with your recovery from surgery, as is usually the case, regular combined follow up with a dietician and a specialist nurse will be arranged.
The key to success with the lap band is keeping it optimally adjusted, making good food choices and slowing down when eating. The band should be neither too tight, nor too loose. It may need a number of adjustments in the first few months to achieve restriction, and in the years after surgery patients will need repeated, usually infrequent adjustments, to keep it optimally adjusted. The optimum diet for the LAGB isn’t all about calories, as is the case with traditional diets. A good LAGB diet, is more about choosing the right textures that give sustained satiety. It’s also important that the patient makes time to eat and changes their eating behaviour, adopting a slow measured rate of eating. This is why specialist LAGB dietary advice is needed. The evidence suggests that patients who have intensive follow up, after their lap band surgery, do better.
This will usually be done in an out-patient clinic, without anaesthetic and takes a few minutes. The patient lies on a couch. The clinician adjusting the band may ask the patient to raise their legs a few inches off the couch, tensing their abdominal wall muscles, which pushes the port forward into a more prominent position. A special huber needle, that doesn’t damage the port, is used to access the port through the skin. Saline is injected into the lap band, which inflates the reservoir inside the band, making it tighter. Following the adjustment, the clinician will check the patient can drink. Post-adjustment, it is sensible to return to a sloppy diet for a day or two. Occasionally the adjustment may be too tight, making it difficult for the patient to eat or drink; for this reason you shouldn’t have your band adjusted just before a trip away.
There is no doubt that the LAGB is the safest operation, with a very low risk of death, somewhere below 1 in 2000. Similarly complications of the operation are also uncommon. Streamline Surgical has done thousands of these operations and personally I’ve done over 500 without serious complications. Your initial consultation will include a full discussion of the risks of surgery, and you will be given a detailed patient information booklet for future reference.
In the longer-term, there are two complications that we worry about, LAGB slip and gastric erosion.
Uncommonly the LAGB can slip, causing a painful blockage of the stomach. It is best prevented by choosing an experienced surgeon, who can fix the LAGB in the correct position, following the advice on eating and not having the LAGB too tight. If it does occur it can normally be managed by removing fluid from the LAGB; occasionally it is necessary to reposition, unlock or remove the LAGB.
Very uncommonly the LAGB can erode through the wall of the stomach. As with slips, it seems to be more common in bands that have been too tight. In this situation, it is necessary to remove the band to allow the hole in the stomach wall to heal.
Nutritional and vitamin deficiencies are very uncommon after LAGB surgery. Nevertheless it is important to follow good nutritional advice to ensure a healthy weight loss. We recommend patients take a multi-vitamin each day and middle aged ladies should take calcium supplements as advised by their general practitioner.
Drug and alcohol absorption is unaffected by LAGB surgery. Fizzy drinks can cause discomfort and are best avoided. Alcoholic drinks have a high calorie content and should be taken in moderation.
Many morbidly obese women don’t ovulate regularly and may consider themselves infertile. Consequently many don’t use contraception. With weight loss many patients will start to ovulate and become fertile. For this reason female patients should consider what form of contraception they wish to use. Following LAGB patients can safely have children but pregnancy should be avoided in the first year after surgery. It is usual in pregnancy to loosen the Lap-Band a little, maintaining some restriction to avoid excessive weight gain during pregnancy
guy.slater@streamline-surgical.com