13 January 2021


Section 15: Gastric band adjustments


As briefly discussed in How the Gastric Band works, the gastric band requires adjustment before its effects are maximised/ optimal. Your first band adjustment will occur a minimum of 5 weeks after the operation, although sometimes your surgeon may suggest you wait longer, e.g. if you had a large hiatus hernia repair – see Recovery. 

When the band is optimally adjusted, providing that you are following all the guidelines described in previous sections of this booklet, you will achieve the following:

  • A background sensation of satiety (not feeling hungry)
  • A sense of satiation (satisfaction) following a small meal.

Remember, it takes on average 4-6 band adjustments to get to this point

 

Our specialist dietitians and specialist nurses will assess your need for the band to be adjusted during your follow up consultations. We do not perform adjustments unless they are genuinely needed. We will always carefully review your status before deciding on adding fluid to the band, because the aim of the band is to reduce your appetite and limit your ability to eat textured/solid food quickly thereby reducing your portion size, not ‘restrict’ you i.e. cause frequent discomfort/pain on eating and/or regurgitation. Problems related to the band are often associated with it being over-tightened.

 

REMEMBER: More adjustments do NOT necessarily mean more weight loss!

 

Before an adjustment

 

We advise you to avoid all food and fluids for at least 30 minutes prior to each band adjustment. If you were to make the mistake of eating too quickly and/or taking too large a mouthful and/or not chew enough and food was to lodge above the band shortly before having the band tightened, this could cause problems.

 

What happens?

 

A band adjustment is the process whereby fluid (usually sterile saline, although contrast solution is sometimes used under x-ray conditions if checking for a leak – see Risks of surgery, potential complications, side effects) is added to or removed from the band, using a syringe attached to a specific type of needle which is inserted into the port underneath the skin, itself attached by thin tubing to the band.

 

It is a quick procedure and no anaesthetic is required.

Adding fluid to the band tightens it so the level of compression on the stomach wall is increased and the stoma (opening) through which each mouthful of food/fluid passes becomes narrower.

Removing fluid from the band has the opposite effect.

You will most likely be asked to lie on the couch, although sometimes it is easier to access the port whilst standing. The practitioner will ask you to expose the area where your port is sited. You may be asked to raise your legs or raise your head/shoulders, because this pushes the port closer to the surface and can make it easier for the practitioner to feel it.

Using aseptic technique, a special type of needle will be used to puncture the skin to gain access to the port area and fluid will be added or removed using a syringe attached to the needle.

You may be asked to drink some water whilst the needle is still in place so that the practitioner can ensure you are able to drink comfortably. You will certainly be asked to ensure you can tolerate a drink of water before leaving the clinic.

Some patients may experience “burping” after the procedure, although this should subside quickly. If it does not, the band may be too tight.

 

How much fluid will be added or removed?

 

Various amounts of fluid can be added to or removed from the band. At your first appointment, the amount added will depend on whether or not your surgeon added some fluid to the band at the time of surgery. 

 

At all appointments, the amount added/removed will depend on:

 

  • The level of appetite reduction you are already experiencing
  • The extent to which the band is helping control the following, therefore helping reduce your portion sizes:
    • The speed at which you can eat textured/solid food
    • The size of mouthfuls you need to take
    • The amount of chewing you need to do
  • The frequency and severity of any discomfort/pain when eating and/or regurgitation
  • To some extent, the level of weight loss you have had. It is important to remember that even with a well-adjusted band, if you are doing one or more of the following, you may not be losing weight:
  • Eating when not physically hungry
  • Eating for longer than 20 minutes at mealtimes
  • ‘Grazing’ i.e. eating for less than 20 minutes at mealtimes, causing you to feel hungry and therefore eat small amounts regularly instead of 3 meals per day
  • Consuming high calorie foods/drinks too often

 

It is important to trust the judgement of the practitioner with regards to the amount of fluid being added to/removed from the band. We have been performing band adjustments for many years and our clinical protocol draws on our significant experience – so trust us!

 

There is no such thing as a ‘small’ or ‘large’ adjustment or a ‘low’ or ‘high’ level in the band, as all patients are different.

 

REMEMBER: More fluid does NOT mean more weight loss!

 

How do I know when I need a band adjustment?

Everyone is an individual. On average, patients require 4-6 adjustments for the band to become and remain optimally adjusted.

The members of our multi-disciplinary team are trained to assess whether or not you require a band adjustment.  

Below is a pictorial representation of when fluid should be added to or removed from the band (source: The Centre for Obesity Research and Education, Monash University, Melbourne, Australia).

Symptoms that may suggest you need fluid adding to the band:

  • You are physically hungry sooner than 4-5 hours after meals
  • The band is not exerting enough control over how fast you are able to eat textured/solid food, and so you are able to comfortably consume a larger quantity of textured/solid food within a 20 minute period than expected

The above will usually occur in combination with lack of weight loss.

 

Symptoms that mean you need fluid removing from the band within the next 48 hours:

  • You are unable to tolerate fluids
  • You are experiencing nocturnal acid reflux and/or night cough

 

Symptoms that mean you need fluid removing from your band within the next week:

Discomfort/pain/heaviness/tightness/pressure on eating, regurgitation, acid reflux or heartburn during the day, occurring more than once or twice a week with a clear cause (see Risks of surgery, potential complications, side effects) OR occurring at any frequency without a clear cause.

These symptoms may result in reliance on soft/high calorie foods that are easy to eat, resulting in sub-optimal weight loss or even weight gain

 

If you need your band loosening, you MUST contact us without delay. Please remember that you may need to travel to an alternative clinic if no appointments are available at your nearest clinic.

How often can I have the band adjusted?

 

After you have any fluid added to or removed from your band, there must be a minimum of 3 weeks before adding any more fluid to it.  This is so you have time to adjust to the altered level of fluid in the band.

You may not feel any different, but it is important to understand that internal swelling occurs as a result of having the band tightened and this needs time to settle.

You also need time to try various different meal and food combinations in order to fully assess any change. 

There can be exceptions to this rule.  If we are readjusting your band following having fluid removed due to an upcoming operation/endoscopy or a long-haul flight/trip to an area of high altitude, we can sometimes refill in stages two weeks apart. This is because we are working back to a level of fluid with which we know you are comfortable.

 

You will be advised by the practitioner at each appointment when your next appointment should take place and their decision is final.

 

THINGS TO REMEMBER

 

  • It takes time for band adjustments to have an effect. Our clinical protocol states that you must wait for 3 weeks between band adjustments to allow them to take effect and for you to adjust to the altered level of fluid in the band.

 

  • In the first few months after the operation, it is normal to need 4-6 adjustments before the band is optimally adjusted. You may find that band adjustments make a difference initially but that this eases off. This is because when the band is placed around your stomach, there is some fat in between the band and the stomach. As you lose weight, this fat reduces in size, meaning that the band loosens off and the effects you felt initially after the adjustment lessen or disappear. This is normal.

 

  • We strongly advise you to see or speak to a dietitian before each adjustment to make sure you are doing everything you can to get the best from the band. We don't want you to have the band tightened unnecessarily, as this can put you at risk of developing complications. A thorough assessment takes place in every band assessment appointment. Sometimes fluid is added, sometimes fluid is removed and sometimes the level of fluid is not altered.

 

Are there any situations in which I can’t have the band adjusted?

We would usually suggest that you do not fly within 2 weeks of having your band tightened - this will ensure you have enough time to check the band is not too tight and to give you time to arrange an aspiration if necessary. Similarly, we usually suggest that you wait at least a week after flying before having any fluid added to the band.

Furthermore, the change in air pressure may affect how tight the band feels (see Other Considerations), and so it is recommended that you do not have fluid put back into the band for at least one week after flying in case it has tightened up during the flight.

Increased stress/anxiety can sometimes make the band feel tighter than usual and so it may not be appropriate to tighten the band if you are feeling particularly stressed/anxious, regardless of the cause.

Hot weather can also cause the band to feel tighter than usual; with this in mind, we do not recommend you travel to a hot climate within two weeks of having the band tightened.

Some women find that the band feels tighter during menstruation, hence it may not be appropriate to tighten the band at this time of the month.

If you are pregnant, it may not be appropriate to tighten the band. See Other Considerations.

If you have reached a healthy BMI (18.5-24.9kg/m2) and want the band tightened to help you lose more weight, we will not usually do this. Our aim is to assist you to a healthier weight and improve any obesity-related comorbidities; the band is NOT a tool to enhance the chances of an ultra-low BMI. However, we do consider each case individually and there are some circumstances in which we may consider adding fluid to your band despite you having a healthy BMI:

  • If you are struggling with hunger between meals or increased portion size, whereby your weight is at risk of increasing
  • In the absence of any signs of malnutrition, you are hungry between meals and/or eating larger portions due to having had fluid removed from the band and are gaining weight as a result
  • You had your band loosened prior to a general anesthetic / endoscopy / pregnancy / when unwell and need it readjusted to its previous level

Will I be able to eat afterwards?

It is essential you progress gradually with your diet after an adjustment, as swelling is present initially that takes 48-72 hours or so to subside.

Phase 1: liquids only for at least the first 24 hours

  • This minimises the risk of any complications associated with tightening the band.
  • The practitioner who performed your adjustment may advise you to extend this phase, especially if they checked how much fluid was in the band initially before replacing it and adding more fluid, as this can cause additional swelling than simply adding fluid. You will usually only require this ‘fluid check’ at your first adjustment to provide a baseline level.
  • “Liquid” defines any fluids that can be poured in a steady stream/flow – this can range from water to a custard consistency Fizzy drinks are not allowed during this period.
  • You should aim for about 2-3 litres of fluid per day, or enough to ensure your urine is pale straw-coloured from around 4-5 hours after waking onwards.
  • Follow the same regime as you did during the first 2 weeks after your operation (see Dietary Advice for Weeks 1-2).

 

Phase 2: soft/sloppy food for at least the next 24 hours

  • Follow the same regime as you did during the second 2 weeks after your operation (see Dietary Advice for Weeks 3 & 4).

 

Phase 3: back to textured/solid foods after at least 48 hours

  • It is at this point that you should start to notice a reduction in appetite and increased control over how fast you are able to eat. After a few adjustments, this will result in a reduction in the quantity of food required at each 20-minute mealtime to stop you feeling hungry. 

 

IMPORTANT: An exact degree of appetite reduction and reduction in portion size can never be guaranteed following an adjustment, and to reiterate – if you are in the early stages of your weight loss journey, it’s important to remember that several (usually 4 to 6) adjustments are usually required for the band to become and remain optimally adjusted. 

 

You may find you need to remain on Phase 1 or 2 for longer than stipulated (see ‘How can I tell if my band is too tight?’).

Switch to a chewable multivitamin and mineral supplement until you are back on solid food. Any medication should ideally be in a liquid form during the transitional diet after an adjustment.

 

What are the risks of this procedure?

You will be asked to sign a disclaimer before undergoing any band adjustment to confirm you are aware of the following risks.

Immediate

  • Slight discomfort/pain.
  • Bruising or haematoma (a collection of blood under the skin, which is usually reabsorbed by the body; rarely, surgery is required to drain the fluid (charges may apply).
  • Punctured port tubing. See Risks of surgery, potential complications, side effects.
  • Inability to access the port. See Risks of surgery, potential complications, side effects.

 

Soon after

  • Bruising or haematoma. See above.
  • See Risks of surgery, potential complications, side effects
  • Symptoms that may suggest the band is too tight. See Risks of surgery, potential complications, side effects
    • Regurgitation
    • Inability to swallow fluids
    • Nocturnal acid reflux
    • Heartburn
    • Pain/discomfort/heaviness/pressure/tightness when drinking/eating

Over 48 hours

  • See Risks of surgery, potential complications, side effects Symptoms that may suggest the band is too tight – as above.
  • The band may become “unclipped”. See Risks of surgery, potential complications, side effects
  • Port may become detached or the tubing may fracture or disconnect. See Risks of surgery, potential complications, side effects
  • The following (commonly caused by an over-tight band):
    • Pouch/oesophageal dilatation. See Risks of surgery, potential complications, side effects
    • See Risks of surgery, potential complications, side effects
    • See Risks of surgery, potential complications, side effects
  • Achalasia/oesophageal dysmotility – these are sometimes pre-existing conditions, the symptoms of which the band can exacerbate. See Risks of surgery, potential complications, side effects.

 

How can I tell if my band is too tight / I am “over-restricted”?

There are a number of signs or symptoms that always, or might, indicate that your band is too tight.

They would usually become apparent within 24-72 hours of a band adjustment.

Symptoms that always indicate an over-tight band:

  • You cannot swallow your own saliva
  • You cannot drink sufficient fluids (leading to a risk of dehydration)
  • You are having reflux more than one night a week (when food or fluid/acid comes into your mouth or nose when you lie down) or night cough

 

If any of the above is the case, you MUST contact us without delay to arrange to have some fluid removed from your band.

Band deflations (“aspirations”) can be arranged quickly in these situations and you can expect us to ensure one of our practitioners is available for emergency deflations within 48 hours of your call to us. Your appointment is likely to be in office hours, so you may need to cancel your other commitments to ensure that you can attend at the time offered. You may also need to travel to an alternative clinic if no appointments are available at your nearest clinic.

If you do require an “aspiration” (fluid withdrawn from your band), we will always endeavour to refer you back to the practitioner who performed the band adjustment. On occasion, though, it may be necessary to refer you to an alternative practitioner (nurse, dietitian, radiologist or surgeon). Charges may also apply, but we will advise you beforehand. If you are unable or unwilling to attend the appointment we offer, we may advise you to attend an NHS accident and emergency department, usually at a hospital with a specialist bariatric unit.

 

If you have any of the above mentioned problems, we do expect you to call us within 72 hours - if you leave it any longer than this following your band adjustment to call us, we do not consider this to be as urgent since you have tolerated it without informing us, and we will arrange your aspiration for as soon as is feasible. If you are outside of your initial aftercare period, there will also be a charge for this appointment.

 

Symptoms that might indicate an over-tight band:

  • You can tolerate fluids but you are struggling (i.e. experiencing discomfort/heaviness/tightness/pressure/pain and/or regurgitation) when trying to progress to soft foods. It could be that you need to stay on fluids for more than the recommended 24 hours.
  • You can tolerate fluids and soft foods but are struggling (i.e. experiencing discomfort/heaviness/tightness/pressure/pain and/or regurgitation) when trying to progress to solid foods. It could be that you need to stay on soft food for more than the recommended 24 hours; it could also be due to poor eating technique (see Risks of surgery, potential complications, side effects)
  • You are experiencing frequent heartburn during the day. This could be due to consuming acidic/fatty/spicy foods, or due to poor eating technique (see Risks of surgery, potential complications, side effects).
  • You are experiencing frequent belching. This could be due to poor eating technique (see Risks of surgery, potential complications, side effects).

 

In any of the above cases, you should contact us without delay to arrange to speak with a nurse or dietitian for discussion, as you may need to have some fluid withdrawn from your band. However, it would not be deemed an emergency since you are able to tolerate fluids comfortably.

 

DO NOT STRUGGLE WITH AN OVER-TIGHT BAND, AS DOING SO PUTS YOU AT UNNECESSARY RISK – CALL US WITHIN 72 HOURS IF SYMPTOMS OF AN OVER-TIGHT BAND BECOME APPARENT

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