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TABLE 1. "Eight Golden Rules" for laparoscopic adjustable gastric band patients
1. Eat three meals or less per day. 2. Do not eat anything between meals. 3. Eat slowly and stop when no longer hungry. 4. Focus on nutritious foods. 5. Avoid calorie-containing liquids. 6. Exercise for at least 30 minutes each day. 7. Be active throughout each day. 8. Always keep in contact with us. From
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TABLE 2. Food intake and appetite at baseline and at 12 months after gastric banding17
COMPONENTS OF FOOD
Total energy (kcals)
Protein Fat Carbohydrate Hunger Score BASELINE
12 MONTHS AFTER GASTRIC BANDING
2,497kcal 114g 98.5g 233g 9 1,020kcal 52.2g 34.6g 98.5g 2
go completely across the band before swallowing another bite. Normally, it will take between two and six peristaltic waves passing down the esophagus, which can take up to one minute. This is probably the biggest challenge of educating the patient who has undergone LAGB. You must instruct the patient to eat slowly— chew well, swallow, and then wait one minute.
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A meal should not go on for more than 20 minutes. At one bite per minute, that is just 20 small bites. The patient probably will not finish the "half a cup" of food in this time. In this case, the patient should throw away the rest of the food. After undergoing LAGB, the patient should always expect to throw away food and to never eat everything on the plate. If it takes between two and six squeezes to get a single bite of food across the band and each squeeze generates satiety signals, then 20 bites should be generating 40 to 120 signals. The actual number will depend on the consistency of the food, the tightness of the band, and the power of the esophagus. With good eating practices and optimal band adjustments, the patient should not be hungry after 20 bites or less. As soon as the patient is no longer hungry, he or she should stop eating. After undergoing LAGB, the patient should never expect to feel full. Feeling full means stasis of food above the band and distension of that important part of the LECS above the band. This destroys the LECS, the mechanism that enables optimal eating behavior and appetite control. A patient should always keep this process in mind.
If the patient finds that after eating the "half a cup" of food he or she is still hungry, he or she should review his or her eating practices, correct the errors, and consider the need for further adjustment of the band. If this is occurring, it is usually an indication that the patient is not in the green zone.
Eat a small amount of good 14 Product Categories
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food slowly. These eight words are the key to success. Small amount refers to small bites, the small fork (e.g., oyster fork), and a total meal size of half a cup. Good food refers to protein-rich, high-quality, and solid food. Slowly refers to chewing well, swallowing, and waiting a minute. Try to repeat these eight words to every patient every time you see them. Get them to repeat it at every meal. The failure of the gastric band can almost always be traced to failure of this process.
ADDRESSING THE CHALLENGES The two principal challenges after LAGB are weight loss failure and the need for revisional surgery due to proximal enlargements above the band. Weight loss failure will occur if the band is not placed or adjusted
Bariatric Times • September 2011
correctly or if the patient does not adhere to the guidelines of proper eating and exercise. When a patient is not achieving results after his or her LAGB operation, the doctor should check to ensure that the band is correctly and safely placed. The most common reason for weight loss failure is poor eating behavior, which leads to enlargement above the band. There are three common eating errors:
1. The patient is not chewing the food adequately. Food must be reduced to mush before
swallowing. If it cannot be reduced to mush, it is better for the patient to spit it out (discreetly) than to swallow it.
2. The patient is eating too quickly. Each bite of food should be completely squeezed across the band before the second bite arrives.
3. The patient is taking bites that are too big to pass through the band.
Each of these errors leads to a build up of food above the band where there is no existing space to accommodate it (Figure 4). Space is then created by enlargement of the small section of stomach or by enlargement of the distal esophagus, both of which can compromise the elegant structure of the LECS. If the LECS is stretched, it cannot squeeze. Without the squeezing, satiation is not induced. When satiation is not induced, hunger persists, more eating occurs, and stretching continues. If our patient continues this each day for a year, it is inevitable that chronic enlargement will occur, the physiological basis for satiety and satiation is harmed, and stasis, reflux, heartburn, and vomiting supervene. The doctor should continually review the Eight Golden Rules for proper eating and exercise with each patient. For optimal weight loss following LAGB, the patient should have access to a comprehensive long- term aftercare program for clinical support and optimal band adjustments and he or she must follow the guidelines regarding eating and exercising for the rest of his or her life. "Eat a small amount of good food slowly" is the key to optimizing the gastric band.
REFERENCES 1. O'Brien P, McPhail T, Chaston T, Dixon J. Systematic review of medium term weight loss after bariatric surgery. Obes Surg. 2006;16:1032–1040.
2. Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361:445–454.
3. O'Brien PE, Dixon JB, Brown W, et al. The laparoscopic adjustable gastric band (Lap-Band): a
The Lap-Band Solution: A Partnership for W
eight Loss