Lap-band surgery fills – should they be done with fluoroscopy? Many Lap-band surgical providers do all of their fills with fluoroscopy and ultrasound. There is an element of safety in doing fills with imaging but is it necessary for every fill? Could there be an element of danger that should be considered? How much does it increase the cost?
Laparoscopic band fills using X-ray fluoroscopy
Lap-band fluoroscopy is performed by a radiologist using an X-ray fluoroscope. The first fluoroscopes were nothing more than an X-ray source with a fluorescent screen between which the patient is placed. You might remember old cartoons and comedies where the character walks behind a wooden box and their skeleton is displayed. As X-rays hit internal body parts they put off heat and an infinitesimal amount of light. The florescent screen captured the heat and light to create images. Modern fluoroscopes no longer need the fluorescent screen (they use something called an image intensifier or more recently a flat panel display)…but they kept the name anyway. Like a typical X-ray, still images can be taken. But the difference between a typical X-ray and a fluoroscope is that the image can be viewed in real time, continuous full motion. So the doctor can view what’s going on in there…as it happens. Modern units include a CCD video camera which can save a movie of a patient’s fill process for subsequent viewing.
Lap-band fluoroscopy – the procedure
Two fluoroscopic X-rays must be performed – one prior to your Lap-band fill and one after. You will be positioned vertically before the fluoroscope. The fluoroscope continuously X-rays your upper torso producing a real time moving image of your esophagus and your stomach. You can easily see your Lap-band, the tubing and the fill port (kind of scary for some people).
You will be given a drink of Barium, just a sip. Barium Sulfate is a radiocontrast agent and is used because it is a heavy insoluble compound that remains opaque when subjected to X-rays. Barium Sulfate is the only form of Barium that is not poisonous and that is only because it is insoluble. All other compounds of Barium are soluble and therefore poisonous. Barium is a heavy metal and some of its compounds are actually used in rat poison.
During the first fluoroscopic X-ray the flow of Barium Sulfate is observed as it comes down your esophagus and fills the pouch created by the Lap-band. There it will stay for only a moment and then flows through the Lap-band into your stomach. The time it takes for the Barium fluid to evacuate is noted.
Then you get your fill. Sometimes the fill table provides support under your shoulder blades to arch your back and tighten the flesh of your stomach to more clearly expose the Lap-band. The port may have been located and marked on your skin during your fluoroscopy or possibly by ultrasound. The doctor injects a specially designed needle through your skin and flesh and into your port. The needle is designed to not core out the pad located at the center of the port that receives it. This avoids damage to the pad. Then a very small amount of saline solution (no more than a couple of CC’s) is either injected or removed depending on the patient’s circumstance.
The second fluoroscopic X-ray (post fill) should show the Barium Sulfate compound either flowing through the Lap-band at a slower or faster rate depending on if saline solution was removed or added. Saline solution is always added for the first fill (the Lap-band is installed fully open) and it is also added if the patient is not experiencing satiety (feeling full) for a long enough period of time. When fluid is added, the Barium Sulfate compound should take a longer time to evacuate (leave) the upper pouch into the stomach. If on the other hand the patient were experiencing regurgitation or heartburn or having problems swallowing, fluid must be withdrawn from the Lap-band. This opens the Lap-band up, allowing the patient to eat more food. During fluoroscopy after saline solution removal (un-fill), the Barium Sulfate compound will evacuate the upper pouch more quickly and in less time.
Can the performance of a fill always be predicted using fluoroscopy?
The real question here is does Barium Sulfate behave the same as food when ingested? The simple answer is no. Many individual factors come in to play that are unique to each person when it comes to determining the correct fill. First, consider diet…some people may eat food that has a close consistency to Barium Sulfate. A correlation (relative similarity in performance) can be made between the behavior of ingested Barium Sulfate and ingested food that has the some consistency. We would love to be able to tell you that all of our patients eat the same food prepared exactly the same way and chew it so it is the exact consistency of Barium Sulfate….life would be easy if that were the case. In reality, every individual’s diet is different so much that no hard rules can be applied. Depending on the individual, you simply can’t predict the performance of a fill by the way Barium Sulfate (a liquid) flows through the Lap-band.
Getting the Lap-band filled to its optimal level or ‘Sweet Spot’ boils down to a process that relies on the doctor’s experience. The first fill occurs several weeks after surgery. A very small amount of saline solution is injected into the device’s fill port, just enough to cause a little restriction. The patient lives with the Lap-band 2 to 4 weeks and reports back to the doctor. Typically the patient reports the amount of time it takes for them to become hungry again after eating a meal; 3 to 4 hours is the target. If the patient becomes hungry after a time period of 3 hours or less, they need another fill. The doctor determines the amount of saline solution to be injected according to the amount of time it takes to become hungry. For example, a patient that becomes hungry in 1 hour or less will receive a larger fill injection than a patient who becomes hungry in 2 hours. An experienced surgeon may be able to dial in the ‘Sweet Spot’ only after 2 to 3 fills. Accuracy depends on the accuracy of the communication from the patient and most of all the experience of the medical practitioner administering the fill. Accuracy in communication between the doctor and patient is very important. Some patients always want their Lap-band tightened. They think that a tighter Lap-band means they will lose weight faster. In reality, an over tightened Lap-band typically results in the patient eating soft high calorie foods that cause weight gain.
Dr. Terry Simpson limits usage of X-ray fluoroscopy for three reasons:
First: it provides very limited information about Lap-band performance. As we have explained the Barium Sulfate liquid does not pass through the body the same way real food does so it provides virtually no information about how the device is going to perform with real food.
Second: We want to limit your exposure to unnecessary X-rays. That being said, we don’t want you to be alarmed about X-rays. X-rays are a very important source of information used by medical practitioners to save lives. It has been estimated that a person could be exposed to 30,000 conventional X-rays in a year without danger of excessive radiation exposure. But, why get one if there is limited value in the information it is going to supply? We don’t want to expose you to radiation, unless it is necessary to do so. Fluoroscopic imaging requires several minutes of continuous X-rays, not just one dose. We of course always do fluoroscopic imaging if any symptoms arise that warrant it.
Third: We save you money (without sacrificing quality and safety). Why do other providers do X-ray fluoroscopy for a conventional Lap-band fill if it provides very little useful information? Typically they have a ownership interest or partnership with the imaging firm. It’s all about making money by selling you services you don’t really need.