The Lap-band is a piece of plastic, and on the inside of it is a balloon. The balloon can be filled with saline (salt water) and this causes the balloon to expand. We fill this band to allow a person to eat a small amount of food, and be satisfied for some period of time.
There are several ways we know you need a Lap-band fill. The simple approach is this: when you eat a small amount of food (three ounces of protein, and a half cup of vegetables) you become hungry within a couple of hours. With One size does not fit allan appropriate adjustment you should feel satisfied for three to four hours with a small amount of food.
Weight loss is a primary indicator of needing a fill. We expect you will lose a pound to two pounds per week until you get close to your goal. If you are not losing this amount, then the reason is simple — you are eating too many calories, and typically it is because the Lap-band needs to be adjusted, or your head needs to be adjusted.
There are those patients who want to know how much fluid is in the Lap-band. The answer to this is simple: too little, too much, or just right. A fill of one amount may be enough for one person, too much for another person, and just right for a third. There is no magic formula, because everyone is a bit different inside. Not only might they have more fat around their stomach, but how they chew the food may be different. I typically chew food five times before I swallow, while my old neighbor chews it 26 times; clearly I will need less of an opening than him. My dog, he needs a Lap-band — chews food three times and swallows it — he would need a larger opening.
Lap-band fills can be done in the office, or in x-ray
The advantage of x-ray is that you can see the restriction, and may have a gauge as to the amount of fluid you are given. An x-ray can also warn of an early slip, too much esophageal dilation, or other problems. In fact, we recommend that our patients have an upper GI at least once a year to determine the status of their Lap-band. The disadvantage of x-ray is the amount of radiation that a patient might receive. Another disadvantage is that what you see on the x-ray is a two-dimensional picture, and may not be right for everyone’s needs. Another disadvantage is drinking the nasty tasting barium. Nothing worse than a patient that glows in the dark.
Fills that are done in the office are easier on patients because they don’t have to drink nasty tasting barium. The fill can typi -cally take a few minutes, and they are on their way, and they are not exposed to excess radiation. The disadvantage is we do not have a picture to guide us, but the X ray view does not take into account the size of food that a person will swallow.
Many surgeons have protocols for Lap-band fills
— they fill a small amount one week, see how patients do, have them come back if they are not losing weight, and fill a small amount again. Some surgeons like to slowly fill a Lap-band, so patients do not go through discomfort.
Those are styles that are debated among surgeons; there is no clear winner in the styles. In fact, many fills are not done by surgeons, but done by nurses, physician assistants, radiologists, or people who are specially trained just to fill the Lap-band. There is an industry setting up called “Fill Centers” where people who have had their Lap-bands placed go to have their fills done. This is especially important to people who have had their Lap-bands placed outside the United States, as many U.S. surgeons will not fill Lap-bands placed in other countries.
After a Lap-band fill we ask the patient to stay on clear liquids for 24 hours and then go to solid food. Typically we want patients to consume 3 ounces of meat followed by one half cup of vegetables for an average dinner.
Our Lap-band pre-fill instructions are pretty simple:
- 1. Be sure you are very well hydrated when you come in for your fill appointment. That means at least 8-10 full glasses of liquid every day for at least several days before the fill. (You really need this amount at all times anyway).
- Drink especially well the morning of the fill. If you’re flying in, it can be much harder to stay hydrated, so take a drink bottle and drink very often! Those little “to-go” packs of Crystal Lite are ideal — ask the flight attendants for a refill of your water bottle, pop one in, and then you will have plenty to drink. Those little 4-oz cups of liquid they give you during flight are useless.
- 2. Be sure not to have any solid foods for at least 6 hours before the fill. Don’t eat a huge or late dinner the night before. If you’re having any trouble (reflux, possible slip, etc). ****Please have nothing but fluids after dinner the night before.
- In some cases, food can still be in the pouch for 12 or more hours.
- ANY food in the pouch will make it impossible to give a good fill, or get a good x-ray
- 3. Don’t drink COLD fluids for an hour before the fill. That will shrink your stoma and may result in an inadequate fill. Room temperature fluids are fine. No ice for an hour before a fill, and drink only room-temperature fluids until your adjustment.
- 4. Avoid getting a fill during a menstrual period or a few days before an expected one. During this time, there is a lot of water retention and the adjustment may not be accurate.
- 5. If at all possible, stay in the area for at least a few hours after a fill. If you live out of town do not return home immediately. It takes the normal swelling after a fill 1-2 hours to develop, and by that time you might be too tight and need to return for an adjustment.
- 6. If you are from out of town plan on spending the night, and catch a plane, or drive home the following late afternoon or evening. If you are too tight, this will allow time to get a small unfill before you leave. This may not be convenient, but it may avoid having to return in a few days, on short notice, in pain, and at high last-minute plane fares! Sometimes you don’t know that you are too tight until a few hours later.
- 7. After a fill, please have liquids only for at least 24 hrs. This allows the stoma to rest and heal.
- 8. Review the eating and food guidelines again before every fill (our Golden guidelines). You’ll need to refine your eating more with higher fill levels, and there will be less room for poor eating behavior — eating too fast, too much, or foods that tend to become stuck in the stoma (dry chicken, bread, rubbery eggs, etc.). As you reach a higher fill level, you will need to be more mindful of what you eat, and to take your time eating.
- 9. Please don’t get a fill if you are having trouble with the current level of fill. If you are finding difficulty with solid meats, or pain when you eat solid meats or vegetables, or having nighttime coughing or reflux, you may need to have fluid removed from your Lap-band. If a band is too tight there is “soft food syndrome” where you can only eat soft foods, this leads to inadequate weight loss. The Lap-band is designed to work with solid food, not soft food.
- 10. The first fills is done six weeks after surgery — but only if you need it. Not before that time. The immediate post-op time is when you need to learn to live with the Lap-band. First with the liquids, then soft foods, then gradually moving to more solid foods. You may very well be hungry with soft foods or liquids — this does not mean you need a fill. Before we can judge your first fill we need you to be on solid food for two weeks. We judge the fill by how long you last with a small amount of food — never by a large amount of food. There are those folks who go for months without needing an adjustment. Your surgeon and their staff will help you decide if you need a fill. There is no rush for fills. Too much can very easily get you in trouble, and you end up further “behind” than if you had gone slower with fills.
- 11. Give a fill at least two weeks to test it. Some fills don’t “settle in” for a week or two, and sometimes more. Your weight loss is what determines how a fill is — remember, we do not want you to “feel” anything, other than being satisfied for several hours after eating.
- 12. One of the most important things in determining if a fill is good is choosing proper Lap-band foods. Soft foods, liquids, junk foods, sweets do not work with the Lap-band, only solid foods such as meats or vegetables. A good test meal is 2-4 oz. of solid meat or fish- and about 1/2-cup vegetables. You should be able to eat about a cup of food (no less) and this should keep you satisfied for about 3-4 hrs.
- 13. Plan regular meals. A good fill will keep you satisfied for 3-4 hrs., but probably not longer. If you are hungry 5 hrs. after lunch, it is not because you have an inadequate fill! Regular meals at planned times are important for a number of reasons, including avoiding snacking, maximizing calorie burn, and normalizing metabolism.
- With adjustments it takes patience and persistence. If you are not feeling satisfied for prolonged periods of time then it is time for a fill. If you go for two weeks without weight loss, and becoming hungry between meals then please make an appointment for a fill. Certainly if you are over-filled make an appointment.
- Trying to speed up the process with a larger volume fill often leads to an over-fill and a lot of discomfort. Often leads to swelling of the stomach to where the entire fluid volume will need to be removed and allow the stomach to rest for a couple of weeks. So be patient. Get use to eating smaller volumes and seeing how long before you are physi -cally hungry again.
Those are our general guidelines for fills (adjustments) that we give to our patients.
The process of Lap-band adjustment is much like new eating habits…
…that we encourage for our patients — slow, small, and easy. The Lap-band is not supposed to be a collar, yanking a person back from eating too much. The Lap-band is a tool, and the adjustments are a part of the tool allowing a person to eat a small amount of food and be satisfied for a long period of time.
Often that we give a person a fill and two weeks later we find that most of that fill is not present in the Lap-band. There are two theories about this — one is that the Lap-band membrane will allow fluid to move back and forth between the body and the Lap-band. The second is that the material in the Lap-band absorbs fluid, and even though the Lap-band is “prepped” at the time of operation with saline (saltwater) sometimes the silicone needs to be wet -ted and absorb some of that fluid. Think of the material that makes up t he Lap-band like a sponge — and it will soak up some of the fluid over a few weeks — once it is soaked the fluid, then the saline we add will stay in the Lap-band. The newer Lap-bands (the AP style) are placed with a small amount and may have less of these issues. So if the first few fills you are keeping track and worried that there is a leak — don’t. This is normal. It is another reason why we recommend a follow up two to three weeks after your first fill.
Leaks can also occur — that is, where there is a loss of integrity of the tubing, the port, or the balloon itself. The balloon loss of integrity is rare, and from information given by the company when these Lap-bands have been examined they have discovered that balloon integrity is maintained unless either the surgeon puts a needle through them at the time of surgery, or the Lap-band has eroded into the stomach, in which case the acids of the stomach eat the lining of the balloon. The vast majority of leaks occur at the port site, or near the port site (where the tubing is attached to the port). The diagnosis of a leak usually occurs at an adjustment, and repair of this is a straightforward operation. Sometimes a radiologist will inject contrast into the port to see where the leak occurs, but often the solution is simply to examine the system under anesthesia. Sometimes the tubing will be in the abdomen and will have to be retrieved with the help of a laparoscope. This is occurs a bit less than 2 per cent of the time — it is an aggravation when this occurs, but we often make the analogy that this is like a fender-bender — not fun, can ruin a day or two, but easy to fix (and sometimes costs a bit).
Sometimes an adjustment means an “unfill.” If you are experiencing episodes of nighttime coughing, reflux then you might need to have some fluid removed from the Lap-band. It doesn’t take much, but it is important. Too tight a Lap-band can lead to poor eating behavior, damage to the esophagus, and even lead to Lap-band slips.
By poor eating behavior we mean soft-food syndrome. Because meat is too difficult to consume then people resort to foods that go down easy — often they are soft foods, mashed potatoes, chips, ice cream, yogurt, soups — all of which go through the Lap-band easily. All of which are high in calories, calorie-dense. The Lap-band does not work with these foods.
A Lap-band will slip when it is tight and a person over eats. The mechanism is pretty simple — and illustrated on the side. But the easiest way to think of it is this: excess food acts as a pile-driver — driving down the Lap-band further onto the stomach. Eventually the Lap-band is so tight around the stomach that nothing gets through — no water, no saliva, nothing. When this occurs we first try to remove all the fluid from the Lap-band and hope the band returns to its normal position. If the Lap-band does not return to its normal position then the only option is to surgically reposition the band.