"Band over Bypass" a Viable Option for People Struggling after a Gastric Bypass.

In a recent issue of Surgery for Obesity and Related Diseases (Jan-Feb 2010) Marc Bessler, MD from Columbia University in New York reported on his group’s experience of placing an adjustable gastric band over the gastric pouch from a previous gastric bypass.

In this article Dr. Bessler said, “We report on 22 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an adjustable silastic gastric band around the proximal gastric pouch.”

The results showed a 47.3% loss of excess weight at 2 years and if you compared their weight with the weight they had before either operation they lost a total of 59.4%

My experience is that most patients that see me in consultation who have not done well after a gastric bypass operation have fallen into one or more of the following situations:

1). They have gone to a location where the program is not very robust and has not helped them to get their best result.
2). They were not well prepared for their operation psychologically and/or nutritionally.
3). They were operated on with a very high BMI and did not lose weight before the operation to reach a BMI of 55 where they are more likely to have a better long term result.

Although it is unfortunate that these patients did not do as well as expected with their gastric bypass operation, the technique of “band over bypass” appears to be the best option at this time.

Other revisions such as changing the length of the small intestine, reduction of the size of the gastric pouch or decrease in the size outlet of the gastric pouch, (call the stoma), with the use of an endoscope have not shown to benefit patients significantly long term.

I have a friend from California who is an attorney that helps people of size gain access to bariatric surgery who has personally done very well with the “Band over Bypass” option and is very pleased with his results.

I believe “Band over Bypass” is the best option presently available for these patients and is not that difficult to perform. Hopefully this technique will help persons of size who continue to struggle despite a gastric bypass operation.

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Why do some adjustable gastric bands "slip"?

Band "slippage" is a frustrating and often disappointing known consequence of selecting an Adjustable Gastric Band as the choice for bariatric surgery. At present I know of no definite way t assure that slippage will not occur after surgery. In fact, about 5% of patients who have an Adjustable Gastric Band placed will need to return for a laparoscopic operation to reposition the band because of "band slippage". usually this occurs several months or a few years after the band is placed and can happen regardless of which product is used, the Lap-Band or the Realize Band.

Actually I believe "band slippage" is a poor name for this problem. Maybe a more accurate term would be "Forced Upward Migration of the Stomach". May be we should even label the problem "FUMOS" after this phrase!

Let me explain why I feel "slippage" is a poor term. When a person that has a gastric band in place eats more than the volume the gastric pouch above the band can accommodate, the extra volume remains in the esophagus. Of course the esophagus contracts forcing the food down into the gastric pouch increasing the pressure in the pouch. Often the patient will experience a severe squeezing pressure sensation in their chest. This force causes pressure on the sides of the pouch. If this occurs repeatedly this is likely to force the stomach wall just below the band to be pulled up or "migrate" up under the band. As the stomach migrates upward the size of the gastric pouch increases. This may occur even though the stomach below the band is stitched to the gastric pouch above the band in an attempt to keep this from happening. As one of our team members,Mike Palasek, RN, CRNFA, says "the determined user can overcome any amount of stitching" and the a gastric pouch will become too large. Also eventually so much stomach is drawn up into the band that the increased amount of stomach inside the band makes the band too tight so that fluid will need to be removed from the band to allow anything to pass through.

In the mean time patients will develop symptoms including vomiting and severe reflux especially at night which is a sign that the band is too tight for the amount of stomach that is within the band. Sometimes the food that comes up is food they swallowed several hours before since the enlarged gastric pouch can store allow more food and it really can not pass through the band.

If you have been doing well with no need for a band adjustment for several months and rather suddenly develop vomiting and reflux "slippage" or FUMOS could be the problem. Sometimes early in the evolution of this problem symptoms are present but the CAT scan will not show enough of a change to make the diagnosis. Your bariatric surgeon should consider removing some of the fluid. If this gives your esophagus a rest and you avoid eating more than the volume of your pouch maybe the "slippage" or FUMOS will not evolve into a problem requiring a second operation.

However, if the problem persists there is a solution. The band position can be revised laparoscopically and placed back in the correct position. I have found that the problem resolves and patients do quite well after the repositioning. To date the problem has not come back. I think this is partially because the patient is careful to not eat more than the volume of the pouch.

In this situation an ounce of prevention is truly worth a pound of cure. I suggest that my patients avoid relying on the band to keep them from eating more than the volume of the pouch. They should use the symptom of squeezing chest pressure in this setting as a signal that they are eating too much too fast. I ask my patients to use their eyes and brain to tell them how much they can eat BEFORE they notice this symptom happens to them. In this way they should be able to avoid putting so much pressure on their pouch that "slippage" or FUMOS occurs.

Now you know my best understanding of why this happens and what you can do to try to prevent this problem. I would be delighted to hear your thoughts or questions regarding this frustrating problem. Just click of the word"comments" in yellow at the end of this posting.

How should a patient that has an adjustable gastric band eat to obtain their best result?

This is the advice I give to all of my adjustable gastric band patients at the time of the office visit about 5 weeks after their operation when I give them the first "fill" or adjustment:Adjustable Gastric Band Instructions:

You are embarking on the next phase of your Journey to significant weight loss and better health.
As you have changed your dietary habits you have:
• Learned healthy nutritional principles and demonstrated them with food
records that were requested by the dietitian.
• Stayed on a liquid diet before and after surgery to allow the band to
heal and transitioned through the phase of soft foods to regular food.
• From this point on protein and vitamin intake will no longer be your major concern.

Now with your first band adjustment your focus changes to how you should eat:

You should eat small volumes of solid food for your meals and snacks. This will allow the food to fill the pouch and pass through the restriction created by the band slowly over the next few hours thus suppressing your appetite. I refer to this phenomenon as “auto-snacking” that is not feeling hungry because some food is slowly being released despite you not eating more food by mouth for a few hours. Liquid foods such as milk, soda, ice cream, soup, milk shakes and fruit juice only serve to sabotage your progress and will blunt your weight loss since they will flow through the narrow outlet created by your band without being slowed by the restriction and you will be hungry soon after eating these liquids.
Wait 30 minutes after eating a solid meal before drinking non caloric liquids such as water or Crystal Light. Drinking prior to this time is likely to only build up in your esophagus and cause you discomfort.
Listen to the signals your body gives you. You should pay attention to how much food you can eat prior to feeling too full. Pressure in your chest is telling you that you just ate more than can be contained in your pouch and food and drink are backing up in your esophagus. You have just eaten too much or too fast or both. If you are experiencing this symptom repeatedly you may put too much force on your pouch and cause “band slippage”. This is likely to occur if you exceed about ½ to one cup of solid food at a time. Learn to eat only this amount. One more bite or drink and you are likely to exceed the amount you can eat comfortably.
Potential Problems:
1). Not keeping your scheduled visits. It is very clear that patients seen in the office each month for the first year do better than those that do not. This is understandable since the band is encircled around fatty tissue as well as around the upper stomach. As you lose weight you are likely to lose some of the fatty tissue within the band as well. This can allow you to eat more food since the opening allowing food out of your pouch becomes larger. In turn this will decrease or arrest your weight loss.
In fact, if this continues you will begin gaining weight again. Therefore, it is crucial that you keep your monthly appointment. In our practice the average weight loss at one year for those who see us in the office each month is 63% of their excess weight. After your fist year the frequency of your office visits will decrease depending on the amount of weight you have lost and your weight loss goals.
2). Don’t drink your calories. Liquids run out of your pouch very quickly, the calories will be absorbed and you will feel hungry soon after taking high caloric liquids for your meals. This is a common mistake and will thwart you weight loss goals. Between meals always select non-calorie containing liquids such as water or Crystal Light. Do not waist your calories on liquids. Skim milk should be used sparingly since it still contains a lot of sugar as lactose despite having the fat removed. Choose high quality protein containing solid foods instead of liquids for your meals and snacks.
3). Eating the wrong consistency and types of food. When the band is adjusted properly, the size of the outlet to the pouch is only about ¼ inch in diameter. Therefore foods such as chicken, steak and doughy breads are not your friends. These are likely to obstruct the outlet of your pouch and cause you pain that will not be relieved until you throw up the food causing the blockage or wait until the particle of food finally passes through.
• Chicken has long stringy fibers and will make a ball much like twine after it is swallowed. Cooking it a long time and /or slicing it thin against the “grain” into very small pieces is likely to help.
• A bite of steak is likely to be larger than the outlet of the pouch unless it is cut extremely small. Of course ground beef is not likely to be a problem since the particles are small. Cooking beef a long time may also help.
• Crackers and toast are likely to form small particles and pass through the outlet of the pouch just fine. However, doughy breads may ball up into a ball in the pouch and “plug up” the outlet.
• Swallowing liquids will only make the problem worse since you would only add to the material that is backing up in the esophagus making it more painful as the esophagus squeezes in an attempt to push the food bolus through the outlet.
• Not chewing enough or eating too fast can cause similar difficulty

Your band is adjusted properly when you are:
• Satisfied with small solid meals
• Not hungry for about 3 hours following a small solid meal
• Not experiencing heartburn or reflux at night
• Losing between 1 and 2 lbs. per week

Your band may be too tight when you:
• Feel you can only take liquids
• Experience heartburn or reflux at night even if you have not eaten for 3 hours prior to bedtime
• Experience frequent vomiting

Your band may be too loose when you:
• Can eat foods such as chicken, steak and /or sandwich breads
• Feel hungry between meals despite small solid meals
• Lose less than 1 Lbs. per week for a few weeks in a row

Exercise:
Exercise is likely to enhance your weight loss and improve your health. However, as you begin an exercise program you are likely to begin increasing your muscle mass and your weight may plateau for a couple of weeks. Do not be alarmed. If you are still experiencing loss of inches despite a plateau in your weight you are likely continuing to lose fat mass and gain muscle mass and your weight lose will soon resume.

Final thoughts for success:
Your band is a tool to use properly. Tools are of no help and can even be dangerous if not used properly. Do not ask too much from your band. Your band is there to remind you how much solid food you should eat at any one time and to help you to manage your hunger. Your band is a tool not a crutch. You should not rely on the band to be so tight that you cannot make wrong choices. You should use your band to remind you to make correct food choices. Your band can help you to control of you eating habits. The band is there to help but do not rely on the band to make you feel “Full”. Use your eyes and brain to tell you how much is the appropriate amount of solid food you should eat at any one time.
If you are experiencing pain that you think is related to your band or having other difficulty that may be related to your band it is best to contact your bariatric surgeon directly or go to the emergency Room of the hospital where you had the band placed. It may not be in your best interest to rely of your primary care physician or another emergency room in case of an emergency. Of course in case of emergency, if you are out of town and cannot reach your bariatric surgeon or visit the emergency room of the hospital where you had the band placed, proceed to an emergency room in that area, preferably to a facility where bariatric surgery is routinely performed.
Finally, if you are vomiting frequently do not assume you have “the flu”. Vomiting in a patient with a band is almost always the result of the band and you need to contact your bariatric surgeon for help.
If you follow these instructions you are likely to be very successful in losing considerable weight, become more active and healthier.

I wish you the very best as you continue on your journey toward better health.

What Do You Think is the Best Way to do Band adjustments?

First, the goal of adjusting a band is for the patient to lose between 1 to 2 lbs. a week with the patient not experiencing hunger for about 3 hours after a solid meal. Of course we do not want the patient to be vomiting or experiencing acid reflux which could indicate that the band may be too tight. If the patient is not losing between 1 to 2 lbs. per week and is hungry between meals an adjustment should be considered.

Bariatric surgeons use several different methods of “filling” adjustable gastric bands.



Some surgeons use a standard volume for each fill without regard to how well the pouch is emptying. They will usually have the patient swallow water before leaving the office to make sure the band is not too tight.

Other surgeons make adjustments under Flouroscopy. In this situation saline is injected into the port to adjust the outlet of the pouch above the band while the patient swallows a chalky liquid. An x-ray machine called a fluoroscope allows the surgeon and/or radiologist to view the liquid as it travels down the esophagus and through the outlet of the gastric pouch into the rest of the stomach. Based on how quickly the fluid empties, the band can be adjusted to change the rate of emptying. This requires doing the adjustment in the Radiology Department or by using expensive x-ray equipment in the office. And this approach exposes the patient to radiation with each adjustment.

The method I have chosen is called a “water test”. With each adjustment I temporarily overfill the band and have the patient sit up and swallow cold water. This will make the water back-up in the esophagus causing a pressure sensation in the chest like the feeling of needing to burp. I adjust the band by removing some of the fluid from the band until the water is released from the pouch and the esophagus. When the patient can drink water without difficulty the adjustment is complete. This allows the adjustment to be made in the office with a high degree of certainty that the adjustment is correct. Also the patient is not exposed repeatedly to radiation.

I have been very pleased with this method. In fact we have achieved an average of 63% loss of excess weight in just one year for those band patients who see us each month in the office for evaluation. Of course, patients do not need an adjustment each time as long as they are meeting their goals.

Can an Adjustable Gastric Band Develop a Leak?

If you do not feel restriction even after the band is adjusted repeatedly you could have a leak somewhere in the system.

Your surgeon may be able to determine that a leak has occurred by withdrawing the fluid from the band to see if the amount is about the amount that has been placed into the band over time. If necessary the radiologist or surgeon can inject contrast into the port and the x-rays can show where the system is leaking.

Actually it is quite rare to find a leak in a gastric band system. In fact I have only had this happen a couple of times over the years I have been placing gastric bands and in each occurrence it has been a leak from the tubing from where the access needle had punctured the tubing. To date this has only happened with the Lap-Band system in my practice. However, it is certainly possible to have leaks at other locations and with other products.

The band should be tested before it is placed into a patient so there should not be a leak as the device is placed into the abdomen. However there are several ways the device can be injured.

1). If the insertion of the device through the abdominal wall is difficult or if the insertion through the trocar that helps with the passage of the band into the abdomen is difficult, the balloon could be torn. Although a tear could be seen by the surgeon and/or assistant it is possible that it is not able to be seen.

2). The balloon could be torn or punctured also by an instrument or a needle as the band is placed around the upper stomach or by the needle as it is sutured into place. Unless it was noted at the time of the puncture it would be very difficult to see this problem.

3). The tubing is unlikely to be injured during placement of the adjustable gastric band but it certainly could be punctured by the needle used during an adjustment. This could occur as the surgeon is trying to access the port. If the needle punctured the tubing instead of the port the water that is placed into the port could leak out of the tubing puncture site, especially when additional fluid causes increasing pressure in the system which occurred in the original higher pressure Lap-Band. Also the connection in the Lap-Band port has an unprotected connection as the tubing leaves the port making it a fairly easy location to injure the tubing. In the Realize Band system the location where the port is connected to the tubing is protected from puncture by metal or hard plastic for about 1/2 inch. It is therefore less likely that the tubing will be punctured close to the port in the Realize Band system.

4). One other possible leak from a Lap-Band system is at the steel connector site where the tubing that leads to the band is connected to the tubing that leads to the port. This can occur as the steel connector is inserted into the tubing or it could occur several months or years later as the tubing becomes more brittle with age. This connector is not part of the Realize Band system and the tubing does not seem to become more brittle with time with the Realize Band material used for the tubing.

To repair a leak in the tubing or near the port the port and or a porting of the tubing will need to be removed and replaced. This is a relatively easy operation and does not require replacement of the band that was placed around the upper part of the stomach. However if the gastric band itself is leak in the band must be replaced.

Therefore, if you are not feeling the restriction you expect even after a few adjustments you should return to your surgeon and ask if a leak is a possible problem.

Band Patient explains her experience

Band Patient explains her experience

"What dietary instructions or suggestions do you have for lap band patients to assist with their success?"

I have found that it is extremely important for lap band patients once they are adjusted properly, to eat primarily solid food and drink non-caloric beverages. Any liquid beverages that have calories in them actually thwart the work of the band. For instance, milk, ice cream, yogurt and fruit juices are high caloric beverages. In addition, soups, especially cream soups are very high in calories. Therefore, all of these calorie containing liquids should be avoided. I suggest my patients to drink water, tea with sweetener, and crystal light, for other liquids. And should always eat solid food, with an emphasis on protein to begin each meal. Liquid should be taken between each meal. One area that is often not considered is the milk that is in a latte. This also is a high caloric liquid and should be avoided.

The good news is that there are a lot of good foods Lap Band patients can eat it is just that high calorie drinks will work against the procedure.