Lap band fills

By drdkim on October 9, 2008 at 3:16 pm

Thank you for revisiting our blog section and, as promised from my previous blog, I’d like to discuss the hot topic of lap band fills. Today, I would like to discuss what I believe to be the “State of the Art Lap band fill’. Patients undergoing bariatric surgery are often times choosing lap band surgery over other types of weight loss surgeries. In America, 50% of all weight loss surgeries are represented by the lap band. The key to successful weight loss is getting an appropriate amount of saline placed in the band. Let me explain.

When a patient is in my office, they often times look at a chart that has 3 bold colors on it- Yellow, Green, and Red

When a patient is in the yellow zone, there is not enough saline in the band. Patients often times feel hungry and over-eat. Many patients feel as if no operation has occurred at all, because there is inadequate restriction. This often leads to frustration for the patient because in the yellow zone, no weight loss occurs. In other word, Yellow represents proceed with caution to continue to fill the band. In the Yellow Zone, patients often can eat just about anything and as much as they want.

When a patient, is in the Green zone, they feel full with about 3-4 oz. of food. They must chew very slowly, because eating quickly can often lead to vomiting. They often have difficulty with a particular type of food. A common food that gets “stuck” is chicken or bread. This means that a patient is experiencing restriction, and behavioral changes are essential for success. As mentioned above, chewing food thoroughly (I recommend 25 times between bites) and not eating and drinking at the same time become essential to adequate digestion. Patients are very happy in the Green zone because they are losing weight at approximately 1-2 lbs per week and hunger is well controlled .No fills are necessary when a patient is in this zone and and we strive to keep a patient perpetually “in the Green”. Further fills lead to patient discomfort and can actually be harmful. More saline at this point sends the patient into the Red zone.

When a patient has entered the Red zone, there is basically too much saline in the band. Patients have difficulty swallowing almost all solid food and sometimes even liquids. They often experience significant heart burn symptoms and mal-adaptive eating behaviors. It is actually possible to gain weight in the Red zone, because protein dense foods are difficult to swallow. Patients are often so hungry because they have difficulty swallowing healthy foods so they have to resort to liquids which are often high in calories or carbohydrate-rich mush foods (like mashed potatoes). Saline must be removed from the band. Excessive vomiting not only makes a patient feel bad, it can cause a slip.

The concept of keeping a patient in the Green zone sounds simplistic in theory, but I think it is difficult to do without Fluoroscopy (commonly known as “the x-ray machine”). For years, I was giving saline fills “blindly”. Especially with the older band models, these bands had only a 4 cc fill capacity so it was possible to add a 1/2 cc or so at a time because the total fill volume was relatively small. Today’s band models have much higher fill capacities. The new Ethicon Realize band holds 9 cc’s while Allergan’s standard and large bands hold 10 and 14 cc’s respectively. I found that blind fills in lap band patients can be very frustrating for the patient. Let’s illustrate an example. If Gail just had an Allergan AP Standard band placed 6 weeks ago, she would be in my office for her first fill. Lets pretend, for the sake of argument,Gails “sweet spot” or when she enters the Green zone is 6.5 cc’s. Using the blind fill scenario, the doctor would place 1 cc then have her come back each subsequent month to add an additional 1/2 cc. If we do the math, it would take 11 months for Gail’s MD to get her to the sweet spot. Obviously, Gail would be very frustrated if it took 11 months for her to feel like she actually had an operation.

Now, let’s imagine Gail entering my office for her first fill 6 weeks after surgery with the aid of fluoroscopy. To visualize this sweet spot, I ask our patients to swallow barium (it’s not as yucky as it sounds-it’s strawberry flavored). Under x-ray vision, we can see if the band is in the proper position. We follow the rate of barium exiting the lap band pouch. By adding saline to the band port, we slow down the rate of emptying of barium. Conversely, withdrawing saline, allows the barium to empty faster. By visualizing this rate of barium emptying, Gail will be in the green zone immediately. This allows her to start losing weight immediately, and avoids 11 months of frustration. Both Gail and I are happy with her steady weight loss progress.

All bariatric surgeries require wise dietary choices and moderate daily exercise. The lap band requires an experienced caring team under the direction of the physician to adjust the band with precision. This precision can only come about using fluoroscopy while the patient is swallowing barium. Safe lap band surgery is needed to place this tool within the patient. This tool will remind patients of the changes that are necessary at meal time. Safe surgery will only take a patient so far however; accurate timely fills with education and compassion allows one to lose 1-2 lbs per week. Depending on a patients starting weight, a patient will reach their target goal in 2 to 3 years. Our office is so committed to the care of lap band patients, we often accept patients who have had surgery elsewhere in the U.S. and Mexico who wish to transfer their care to us.

There is one last bit of advice I’d like you to heed. If you choose lap band surgery, please choose a program that is a Center of Excellence (COE designation) because these programs have been deemed by the American Society of Metabolic and Bariatric Surgery to have complete programs with the highest degree of success. These COE designated centers are supposed to help the consumer/patient identify the best programs for the bariatric patient.

Until next time, stay well. David Kim, MD FACS

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