Lapband Slips



MYTH: If a band slips it the band must be removed
Band do not have to be removed if they have slipped. A number of times (about 85%) the slip can be reversed by removing all the fluid on the band and going on a liquid diet. The remaining time bands can be either repositioned or unbuckled – later to be re-buckled.

The band is put into a patient in so that it is just below the junction between the esophagus and the stomach. it is placed at an angle pointing to the left shoulder
Band X ray
You can see the band placed with just a small pouch of stomach above it. This is normal band placement.

Bands Really Don’t Slip
A band slip sounds passive. But it isn’t passive. A band doesn’t slip – it is the result of the person either (a) Eating too fast or (b) Getting something stuck, or repeatedly getting something stuck.

After a band is placed, if someone eats too fast, then food is above the band in that small bit of stomach. This is stretched, and the body’s normal reaction is to vomit. But constantly eating too fast patients notice that the vomiting stops (sort of) because they have stretched that upper pouch by repeatedly packing that upper pouch with food.

Mechanism for a Band Slip
Food packing in the upper pouch, forces the pouch to stretch and for stomach to be pulled up above the band.

These forces – food packing in the upper stomach – lead to both dilation of the stomach above the band and pulling stomach up into the band.

These can lead to x-ray findings like this:

Early dilation of the band
This x-ray shows the band with a dilated esophagus, as well as a dilated pouch above the band. In this case the symptoms were caught early enough and the patient’s band was unfilled and the patient placed on a liquid diet.

The patient came in with symptoms of reflux, heartburn, and night cough. But also felt like she needed MORE fill, because she was hungry. Those symptoms are a concern, so an upper GI test (we call it an esophogram) was done after removing all the fluid from the band.
You can see that the band is still in the normal position here – but food packing – either from eating too fast, or getting too many things stuck led to chronic dilation.

FIRST STEP: REMOVE THE FLUID FROM THE BAND, THEN PLACE ON A LIQUID DIET
In the above case she was placed on a liquid diet for two weeks. And two weeks later the x ray showed complete resolution of the problem.

Once the issue was identified – in this case, the eating behavior was trying to use the band to keep from eating too much – and not using it to suppress hunger – the patient was taught, again, the proper way to use the band and to eat slowly, and avoid foods that became stuck (bread, pizza, over cooked proteins, stringy vegetables).

A WORSE LOOK:
Sometimes patients will go on for weeks with reflux, heartburn, seeing physician after physician and not getting any better, eventually finding themselves back to the band surgeon. This was the case of this person:

Band Slip
The x ray shows a clear band slip. The band is now in a reverse orientation, the stomach has been pulled above the band

This is a classic slip. The upper stomach has not only dilated, but pulled more stomach up.

Here is a diagram of what it looks like:

Diagram of what the dilated stomach and horizontal orientation of the band.

Almost a muffin top.
THIS CAN BE SAVED.

Too often I have seen patients with this who have had their bands removed by surgeons- stating such a situation cannot be salvaged.

First step: remove the fluid from the band. If contrast goes through the band then it is worth a trial of conservative therapy (placing the patient on liquids only for two weeks to see if it resolves.).

Here was an x-ray sent to me by an outside hospital of a patient who came in complaining of several days of inability to eat solid food, and constantly vomiting. The local surgeon said it was a band slip and the band needed to be removed.

Band slip
You can see the upper stomach that is both dilated, muffin-top above the band that has a reverse orientation (instead of 7 or 8 o’clock to 1 or 2 o’clock it is now 10 o’clock to 4 o’clock)

This patient can tolerate fluid – and it is important that the patient ONLY drink liquids- no solids at all. Thicker liquids often do better. Sips- not guzzle, and continually. Over time this will resolve.

BUT WHAT IF IT DOESN’T
There are three choices:
(a) Remove the band entirely. This can be done as an outpatient. WHen removing the band there will be a capsule of scar tissue around the band and it must be lysed on the stomach or the patient will continue to have symptoms.

(b) Unbuckle the band and lyse the adhesions on the stomach. This is safer than (a) because you are not pulling the band out from a dilated stomach

(c) Reposition the band. If the upper pouch is too dilated this is not recommended. IN fact, the only time this should be done if the slip is acute, and the stomach easily goes back down. If the pouch is dilated, putting the band in can lead to a perforation a few days later.

Conservative therapy helps 85% of the time. Unbuckling the band will provide immediate relief, and typically two months later the band can be re-buckled and if some re-positioning needs to be done, the pouch is much less dilated.  Before returning a patient to surgery, an esophagram will help determine if the band needs repositioning.  It is critical to remove the scar tissue, without removing it, there will be continued issues.

In our series – over 85% of patients who had a slip resolved with removing all the fluid, and placing on a liquid diet. There have been patients who have come to us with complete obstruction, and the first rule is to have them re-hydrated with iv fluids and then take them to the operating room for an unbuckle. The anesthesiologist often do a rapid-sequence intubation or an awake intubation in these cases.

WARNING:
If you have a slip- you should follow the instructions of your band surgeon. Some surgeons remove bands that have slipped as a matter of policy- later to convert the patient to another operation – feeling that the band has failed. We have found that over 98% of patients who have had slips never recur again, and use their band successfully. There is no standard of care – just opinions between surgeons. Again, your surgeon is the best judge of what you should do, and it may be that you can have your band rehabilitated, but it may be that the band will simply not work as an option for you.

The key to all weight loss is lifestyle changes: all weight loss operations require them. Patients unwilling to cook differently, or to cook, or unwilling to eat differently will probably only temporarily succeed with another weight loss operation.

Dr Terry Simpson About Dr Terry Simpson
Dr. Terry Simpson is a Phoenix weight loss surgeon. He encourages his lap-band surgery patients to learn to cook and adopt healthier lifestyles. His goal is to use culinary medicine to keep patients out of his operating room. in 2017, Dr. Simpson became a Certified Culinary Medicine Specialist.


About Dr Terry Simpson

Dr. Terry Simpson is a Phoenix weight loss surgeon. He encourages his lap-band surgery patients to learn to cook and adopt healthier lifestyles. His goal is to use culinary medicine to keep patients out of his operating room. in 2017, Dr. Simpson became a Certified Culinary Medicine Specialist.
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