When talking about the Lap-band, some patients talk about restriction. Let’s first be clear about one thing: the purpose of the Lap-band is not restriction; the purpose of the band is to lose weight.
Restriction is not a sensation that you are use to before you have the Lap-band; it is a totally different sensation. When you eat Thanksgiving dinner, and become stuffed — that is not the same sensation of restriction that you will have after a Lap-band. Being stuffed after a large meal is a complicated sensation of the abdominal wall stretching, of a lot of gas in the bowel, in addition to feeling a dimming of appetite. It is the subtle dimming of the appetite that the Lap-band should provide, you will not, and should not, feel the abdominal wall stretch, you should not feel the “near nausea,” and you should not feel bloated.
So when we talk about restriction we mean that the appetite is dimmed, just dimmed — not stuffed — dimmed. It is not a forceful feeling, but a subtle one. As a result you eat less, because you will not have the “appetite” to eat more. You can make better choices, and hence you will lose weight.
Here is the most important point: You should NEVER eat until you feel full. It is best to stop eating before you feel full. If you eat until you feel full you will not be successful with the Lap-band — and may risk having the band slip. The nerves from your stomach to your brain are slow — they will tell your brain that you are full ten to twenty minutes after your stomach is full. If you eat until you feel full, that is when your brain tells you that you are full, you will overeat the pouch — causing the pouch to stretch beyond its limits, and ultimately can force more stomach above the Lap-band, resulting in a slip.
Some think that a restriction is when you eat too much you vomit, or wish you would. Some think it is when you feel stuffed. The other name for this sensation is called the “hard stop.” This is not how the Lap-band is supposed to function. The dangers of vomiting are so important that we devote a chapter to them. But know that vomiting is a symptom, one of overeating that leads to the Lap-band to slip, leading to another operation. But it isn’t vomiting that leads to slip, really — it is stuffing that upper pouch with food that leads to slips. To preserve your Lap-band requires that you change your thoughts about a hard stop. The reinforcement that you would vomit if you ate too much, or that food is always getting stuck in your throat, or a “hard stop” is dangerous, and will not promote weight loss or a change in lifestyle that leads to permanent weight loss.
Hard stops with Lap-band Surgery – the road to a band slip
Misinformation is abundant in the world of Lap-bands, but sometimes the sensations are reinforced. The hard stop is reinforced after the first fill of the Lap-band. When the Lap-band is first filled, the upper pouch — which measures around one to two ounces is thick and hard to stretch. When food is eaten, it arrives in this pouch, and meets some resistance — first against a newly adjusted Lap-band, and secondly because the stomach is thick and does not stretch easily, and third because the Lap-band resists the temptation of the stomach to pull up through the Lap-band to make more room for more food. People love this feeling! It is a sense of control over food — a leash. But it is not real.
The first bits of food you put in, after a Lap-band has been placed, or adjusted, causes a small stretch in the stomach, and it is difficult to put in more food. As time goes on, against a tight Lap-band, the upper pouch will stretch a bit, but only to a point. Wanting that feeling of resistance again, that hard stop, it takes a bit more food, or a tighter Lap-band. This is when people generally want an adjustment, coming to the office and saying, “I can eat a whole lot more.” It is becomes difficult to dissuade them that this is not the sensation we want them to have, and they become discouraged when we tell them that this may have been the last time they feel that sensation of restriction. There are a group of patients who keep their Lap-band too tight. Wanting to “feel restricted.” The problems that can result from this misguided thought can include a dilated esophagus, a dilated pouch, and a very tight Lap-band.
After continuing to fill the stomach it will stretch to the point where that sensation of resistance requires more and more food. More food is required to feel the sensation your brain interprets as being full. Three things can happen — one is that you will force food out of the upper pouch into the lower pouch. Another is that you will vomit. But what is most dangerous is the stomach below the Lap-band is pulled to the upper pouch to accommodate the excess food. So, that small pouch gradually enlarges — not because it is being stretched, but because the increasing amounts of food placed into the stomach force the Lap-band down (slips) and pulls more stomach above the Lap-band – making the upper pouch larger. Ultimately the packing of food above the Lap-band leads to a band slip. We call it a slip — but the band doesn’t slip — the stomach is being pulled up to accommodate more and more food.
You can always — always, always, always, force more food into your pouch. Imagine a long balloon when you first blow it up. The first few breaths take a lot of effort, but as soon as the balloon starts to stretch it becomes easier and easier to blow air into it. The stomach is a lot like a balloon. The larger and thinner the balloon becomes, in this case, the larger and thinner the stomach becomes — less muscular, less resistance there is less of a sensation of “fullness.” The stomach can stretch, and part of that is good, because in stretching a bit you send the brain a very subtle signal that it is satisfied. But if it keeps stretching, and keeps stretching then you can lose the effect of being satisfied with less, because the stomach will need more to fill that upper pouch up as more stomach is brought to the upper pouch. Like the balloon, you will be able to eat more and more and against a fixed Lap-band you risk dilation of the esophagus as well as a prolapse, or slip, of the stomach above the Lap-band to the point where the band is now around stomach that is thicker and thicker (in essence the food is serving as a pile driver — pulling stomach above the band and forcing the band further down the stomach).
The sensation we want from the Lap-band is satiety.
Satiety is the ability to eat a small portion of food, and be satisfied with it for a long period of time. Not the sensation of fullness. Instead eating a small amount of food, allowing it to remain in the upper pouch, and feeling satisfied (not hungry) for several hours. Early on you leave the table feeling hungry. If the Lap-band is working, then the sensation of being hungry is really emotional, that is, you think you should eat more because you normally do. The brain needs to be retrained with this. And ultimately it will be. Once your brain realizes that a small amount of food keeps you satisfied, and then your eyes will adjust to the amount you eat. But the “hard stop” where you cannot eat any more is not the desired reaction.
The Lap-band is working if you feel full with a cup of food, or sometimes less, and it takes a few hours before you feel hunger again. That is the “soft stop.” This is lifestyle change — the ability to gauge the amount of food you can comfortably eat, knowing it will keep you satisfied for several hours.
The band goes around your stomach, not around your brain. If you want to eat bread, pasta, processed foods, and expect that the Lap-band restriction will enforce a time for you to quit — it won’t happen. Soft foods go through the Lap-band, they do not allow satiety.
There may be times when you will eat too much, or too large a piece of food, or eat too fast and you can regurgitate the food — sometimes called a “productive burp,” or PB or “bandster burp” — BB. These things can happen, no one is perfect, they happen. But this is an unwanted, and unnecessary sensation. This is when the Lap-band will remind you about restriction, and not remind you about losing weight.
There are times when the band will seem tighter than others. In the early morning it is common for the Lap-band to feel tighter, meaning some patients will need to skip breakfast, or put breakfast off if they are a bit too tight. Other times when the Lap-band has been tight include allergy season, times of stress (ok, blame the boss for not eating now, instead of eating), menstrual periods, or if you encounter some poison ivy or poison oak. If the Lap-band, during these times, produces an unwanted “hard stop,” the Lap-band might be too tight and you may need to have your band emptied for a bit.
One thing that causes the Lap-band to become tighter is persistent vomiting. If you start to vomit, and attempt to keep eating, the mucosa (inner lining) of the stomach becomes thicker and swells, and eventually it will obstruct the outlet of the Lap-band. Hence, when patients start to vomit, we encourage them to stop eating and drinking for a short period of time, usually two to four hours. If you persist in vomiting you may obstruct the Lap-band. Once the Lap-band is obstructed, then it will need to be unfilled. Sometimes such edema of the inner lining of the stomach resolves in a few days, often it does not. One of the advantages of the Lap-band over more permanent weight loss operations (the RNY-gastric bypass, the vertical banded gastroplasty, or the duodenal switch) is that it can be adjusted — in those operations patients must either be placed into the hospital on intra-venous fluids and kept without food or water, or sometimes even have their restriction dilated endoscopically — which may ruin their restriction permanently.
The sensation that we want the Lap-band to produce is a “soft stop”
The soft stop is where you stop at a “bandster” portion of food, and move away from the food. It doesn’t produce a hard stop — it isn’t a 2×4 whacked across your head. But after eating a “bandster” portion of food, you should be satisfied for several hours. You can always put more food into the upper pouch because the sensation of feeling full, or “satiety” is a slow reflex; it takes a while to get to the brain. Which is why you eat a small portion of food and then walk away — knowing you have eaten enough to fill the pouch, to stretch it a bit, and the brain will know that you are satisfied. But you have not eaten so much food that you are near nausea, or that you become uncomfortable.
Often patients will tell me that they think they need a fill because they can eat more than they could before. The obvious question is “Why are you eating more?” The Lap-band does not restrict the quantity of food you put in your mouth, that is your job. The Lap-band does not restrict the types of food you put in your mouth, that is your job. The Lap-band will not stop you from eating more; that is your job. The Lap-band will not stop you from stuffing more food into your pouch, it cannot. Stuffing might make you uncomfortable, but that is not the job of the Lap-band. The Lap-band is empowering; if you eat an appropriate amount, make appropriate choices, you will be satisfied for several hours, and either lose weight, or maintain the weight loss at your goal. The purpose of the Lap-band is to lose weight, and you lose weight by making wise choices about what you eat, eating an appropriate portion and walking away. The Lap-band is a tool to allow you to be satisfied by eating less. The Lap-band is a tool for you to use, to help adopt a healthy lifestyle — you still have choices to make, the Lap-band simply allows you to be satisfied with healthy choices.
Never put more than a “Lap-band” portion of food on your plate
If you are hungry later for more, then you can make that choice. But if you have more on your plate than you should, chances are you will consume it. You should not rely on the Lap-band to “restrict” the amount you are eating.
“If I could eat less and walk away, what would I need this Lap-band for?” You ask. This is the difference between before the Lap-band, and after the band. Before the Lap-band if you tried to eat a smaller amount of food — you would find yourself hungry and wanting more — possibly leading to grazing, or snacking. With the Lap-band you will feel satisfied — not stuffed, not ready to vomit, simply satisfied. Eating less now works.
How are you restricted? Chances are you are not restricted, instead of the sensation of feeling restricted; we want you to have the sensation of feeling satisfied. The Lap-band is a simple tool that allows you to be satisfied, and satiated, with smaller amounts of food. Your ability to eat won’t be restricted, but the sensation of “hunger” an hour or two after eating a small amount of food is gone. The purpose of the Lap-band is to be a tool — to empower you to eat less, have your appetite dimmed, and therefore lose weight.
There can be consequences for eating until feeling full with the Lap-band
Too much restriction — or, too hard stop-leads to esophageal dilation as well as upper pouch dilation. The esophagus is a tube that leads to the stomach — the esophagus can stretch, and will. If you have a very restricted outlet, things back up. If you wait until you feel overstuffed, or feel too restricted then the food will back up, and the pouch and the esophagus will dilate. A dilated esophagus becomes like a second stomach — you can fill it with more food, and then you feel as if you have no restriction, because you can eat more. Again, if you only eat a bandster portion, then this doesn’t become an issue.
The purpose of Lap-band surgery is weight loss. You do not need to feel “tight” or “restricted” to lose weight. Many people lose weight just because their appetite is dimmed. People also lose weight because they eat a small portion, stop, go do something else and feel comfortably satisfied. You don’t have to vomit to lose weight. You don’t have to eat until you just can’t possibly squeeze any more in.
Still many Lap-band surgery patients feel the way they should lose weight is to eat until they cannot eat any more, or they feel as if they are stuffed. There are many ways to overcome the Lap-band: you can drink liquid calories, eat soft food, and eat frequently (graze). You can flush the food through by drinking with your meals, eat high calorie, high fat foods and thus you can continue to consume too many calories.
Lap-band empowerment doesn’t come from stopping you from eating more — Lap-band empowerment comes from the band allowing you to eat less and feel satisfied for hours.