Ten little-known truths every bandster needs to know

1. Bands don't work without fills. It is occasionally claimed that even an unfilled band can lead to significant weight loss; however if that is ever true than it is far more likely to have been a psychological effect (similar to placebo tablets). For this reason, bandsters should always recognise that there must be an aftercare programme in place following their operation, and this is especially important if their surgery took place abroad. Very few bandsters achieve adequate restriction with less than 4 fill steps. Modern bands are designed to withstand several thousand port membrane perforations, so having a lot of fill adjustments is not a problem as long as a non-coring Huber needle is used.


2. Most bandsters lose little weight until they reach good restriction following several fills. This is in contrast to malabsorptive (permanent) surgerywhere much of the overall weight loss occurs early. Any weight loss in the first several months while the band is being filled in a stepwise fashion, is a bonus and likely to be the result of voluntary food limitation. Bandsters lose most weight in the 12 months following the restriction kicking in. It is common for bandsters to think their operation was a "failure" because there is little weight loss initially, and more than a few give up on their band quite quickly - DON'T!


3. The initial fills to achieve restriction must be carefully measured and spaced out in time. Even though most patients end up with a long-term fill volume in the region of 6 - 9 mls (some band types are designed for less), it would be madness to try to get there in a single fill. The top of the stomach, including its blood supply, is becoming gradually "strangled" by the expanding band, and if any increase in the pressure exerted by the band on the stomach is too sudden or too much, restriction becomes total and a medical emergency is on the cards! For this reason, filling the band must be done in several steps, and the individual additional fill volumes will get smaller and smaller.


4. Good restriction is a moving target. Restriction can change over time with natural processes such as periods (water retention leading to a tightening), illness (e.g. dehydration leading to a slackening) and changes in barometric pressure such as during extreme weather and on airplanes. Restriction normally changes even throughout the day - early in the morning after a night spent horizontally, body water is equally distributed everywhere along the length of your body and your restriction will be tight, making breakfasting difficult. Once you get up, gravity displaces some body water downwards from the upper part of your body, getting rid of "baggy eyes" and loosening band restriction as the stomach wall gets less oedematous. Following significant weight loss and reduced eating volumes, your stomach itself will also have shrunk, and the band thereby gotten looser - this is normal.


5. There are two distinct phases to your postoperative life: Excessive weight loss, and maintenance. The first needs tight restriction and should not take much more than a year; the second requires some (less) restriction and lasts forever after - or however long the implant lasts. During the weight loss phase, you must be sufficiently restricted to have food/fluid regurgitation (productive burping) at least some of the time. If, prior to your operation, the prospect of this is a problem for you then gastric banding may not be the right approach.


6. Every type of weight loss surgery can be defeated through persistent high-volume or high-calory food intake. This is why psychological evaluation is so important - if the patient is fundamentally unwilling to change their eating/drinking habits, the surgery may be ineffective. Gastric banding is far more than simple plumbing; even with a band in place, half the battle will still be in your head. Anyone that tells you otherwise lives in cloud cuckoo land.


7. Temporary defills may be necessary. This usually occurs after too large a fill step, in the setting of illness (especially when it involves nausea and repeated vomiting which will set up an inflammatory cycle that damages the stomach and causes more vomiting). Dehydration from excessive restriction, if allowed to persist for too long, can become life-threatening - see point 3 above. Unfortunately not every hospital has a bariatric surgery programme, and while patients unable to keep fluids down can be rehydrated by an intravenous drip, unfilling by a trained professional may be necessary and this is currently unavailable in many district general hospitals. Note: Attempts to access a port with ordinary needles are likely to cause damage to the port membrane resulting in leakage and the need to replace the port - insist on expert care with specially designed (Huber point) needles!


8. There is a small but not negligible percentage of post-surgical complications. These include band slippage, port flipping, filling leakage, band erosion into the stomach itself, acid reflux, and gastric bleeding. These need to be recognised in a timely fashion and treated appropriately if the band is to remain effective and harm is to be prevented. At this point in time, many GPs do not have sufficient in-depth knowledge to be able to confidently distinguish between self-limiting and serious problems, so if your restriction changes noticeably or you experience persistent stomach problems then you may need to insist on a referral to a specialist. Gastric banding is the safest form of bariatric surgery, but is not risk-free.


9. Weight loss surgery has been scientifically proven to be the only currently available medical cure for high blood pressure, diabetes and osteoarthritis in obese patients. Tablets can control the symptoms but will not lead to a cure - weight loss does.


10. Most bandsters tend to believe any problems they experience are unique to them and quite possibly their fault. In all likelihood they are mistaken on both counts, but it takes effective communication to discover this. Patient-led websites and community blogs can be enormously helpful in this regard!