Frequently Asked Questions about LAP-BAND® Adjustments
By Dr. David Provost

Q: Why are adjustments important?

A: Ongoing adjustments, either adding or removing saline from your LAP-BAND System, are necessary for continued success with your LAP-BAND System.  This unique feature provides the right level of restriction for your individual needs.

Q: When do I need an adjustment?

A: It is important to remember that everyone requires a different amount of restriction and a different adjustment schedule. But, several indicators may alert you to schedule an appointment to have a LAP-BAND adjustment. Some of these include:

• No weight loss for more than four weeks
• Increased appetite
• Feeling hungry less than four hours after eating a meal
• Ability to eat more food during a meal than usual
• Increased snacking
• Ability to eat foods that you were unable to eat before (i.e. white breads, fibrous vegetables)

Q: How do I know that I have been properly adjusted?

A: You should feel an early and prolonged satiety, or fullness.  Small meals should satisfy you while maintaining a target weight loss of 1-2 pounds per week.  The LAP-BAND makes you eat less and feel full in two ways -– first, by reducing the capacity of your stomach, and second, by increasing the time it takes food to get through the digestive system.  If you follow the nutrition guidelines provided by your surgeon, when you choose your food and then chew it well, you should not feel hungry or deprived.

Q: Can I be over-adjusted?  If so, how will I know if I am?

A: Yes, there is such a thing as too much saline in your band.  Tighter is not always better!  Indicators that you may be over-adjusted include:

• Difficulty swallowing
• Unable to swallow saliva
• Foaming at the mouth
• Regurgitation
• Waking up at night coughing or vomiting
• Frequent reflux/heartburn

If you experience any of these symptoms, you should contact your surgeon’s office immediately.

Q: Why do I feel more restricted in the morning than I do at night?

A: Your esophagus muscle, like any other muscle, tightens when not being used overnight.  Your esophagus must work to push food down through the band and needs some “stretching/warming up” in the morning. Often, this results from eating a larger meal in the evening without sufficient time to empty your pouch prior to lying down for sleep.  Try making your evening meal smaller and not eating for 3-4 hours prior to bedtime.

Title: Informational Meeting
Location: Presbyterian Hospital of Denton, Meeting Room 1&2
Description: Dr. Provost will meet with prospective WLS patients who are considering weight loss surgery
Start Time: 6:30 p.m.
Date: 12-16-2008

Provost Bariatrics coordinates complete, multidisciplinary care for obesity surgery patients, including nutritional, psychological, and rehabilitative care. The practice also sponsors regular support groups for pre- and post-operative patients.

PRE-SURGICAL CONSULTATION
During your initial visit, Dr. Provost will carefully explain the details about weight loss operations, including the risks, benefits and dietary changes that can be expected, and he will answer any questions you may have. If you decide to have surgery, we will contact your insurance company to obtain approval (see below). Occasionally this may take several weeks, and appeals may be necessary. Once approval has been obtained, we will schedule a date for surgery. 

A second visit is required prior to your date of surgery to review the risks and benefits and perform a complete physical examination. You will then be escorted to the hospital day surgery area to complete your preoperative evaluation. There, you may meet with nurses, anesthesiologists, dieticians, physical therapists, and other providers who will participate in your care while in the hospital. 

You will return to the hospital the morning your surgery is scheduled. Dr. Provost will again meet with you prior to your surgery. The majority of our gastric bypass procedures take from one and a half to two and a half hours. Recovery time in the hospital following your surgery is usually one to three days, depending on the procedure. You will return to see your surgeon about one week following discharge for an examination, to remove sutures or staples if necessary, and to advance your diet. An additional visit is required at 4 to 5 weeks for gastric bypass patients to discuss the next stage of dietary changes. Additional follow-up visits are maintained at 3 month intervals for the first year or two following weight loss surgery, then annually for life.

INSURANCE OPTIONS
We strongly recommend that you attend one of our monthly information, question-and-answer sessions prior to your initial appointment to learn about the different surgical treatment options and whether insurance will cover your procedure. You can also check your health insurance policy or inquire with your human resources department to determine if surgery for obesity is a covered benefit, and what requirements are necessary. Both gastric bypass and the Lap-Band procedure are covered under Medicare, when medically necessary. 

To expedite the insurance approval process, our office will contact you prior to your appointment to confirm coverage and that all prerequisites have been met. Please bring a written record of previous attempts at weight reduction, as well as copies of medical records from any physician-supervised weight loss programs. Cash payment plans are available for patients who choose to pay for their weight loss surgery out of pocket.

The biggest change will be in your portion size. If you’ve been to a restaurant recently, you know that what is considered a normal serving size in the U.S. is often enough food for three people. If you’re used to sitting down to a heaping dish of pasta or a large steak and stuffed bake potato, you may be surprised at just how little food you add to your plate following weight loss surgery.

After either gastric bypass or gastric banding (Lap-Band) surgery, you will only be able to eat a few bites at each meal. You must take small bites, chew your food well, and eat slowly, taking two to three minutes between each bite. By slowing down, you will be more aware of what you are eating, and are more likely to feel satisfied sooner. Most importantly, you should stop eating when you become comfortably full or are no longer physically hungry. Overeating or eating too quickly will result in discomfort or vomiting. Similarly, you will no longer be able to gulp large volumes of liquid when thirsty, and you will have to learn to drink water continually throughout the day to prevent dehydration.

FOOD CHOICES
After a gastric bypass, the types of food you eat will also change. You may have difficulty eating tough meats, particularly beef, following surgery. And, you should avoid greasy or fried foods, because your body cannot process them the way it is used to and they can make you feel ill. You generally won’t have a problem with most vegetables, although you may want to avoid raw vegetables, such as broccoli, celery or carrots. Carbonated beverages, even diet sodas, are a big no-no. They can stretch your pouch, limiting weight loss, and defeating the purpose of the surgery. And, if you know anything about the gastric bypass procedure, you know that foods high in sugar cause the dumping syndrome, which causes light-headedness, sweats, a jittery feeling, nausea, and vomiting. Cake, candy, ice cream, pies, cookies, and other sweets and desserts all can cause dumping and are off limits. (Artificial sweeteners, however, are permitted.)

With the Lap-Band procedure, adherence to the prescribed eating habits is equally important, and follow-up visits with your surgeon for adjustments are essential to long-term success. If you do not go back for routine fills to maintain the appropriate amount of restriction for the Lap-Band, you can easily regain the weight that you lost after your initial procedure. When the Lap-Band is adjusted correctly, you should feel full or satisfied fairly quickly. If small meals no longer satisfy you, if you still have weight to lose but have plateaued, or if you find yourself snacking more often and eating foods you previously couldn’t eat, like white breads and fibrous vegetables, then you are probably overdue for an adjustment. Overall, if you follow the nutrition guidelines provided by your surgeon, when you choose your food and then chew it well, you should not feel hungry or deprived.

PROPER EXERCISE
Exercise is an essential component of any weight loss program, and both the gastric bypass and Lap-Band procedures are no exception. You will be expected to begin a daily walking program upon discharge from the hospital. Patients who are unable to walk due to joint or back problems are encouraged to participate in alternative methods of exercise including water aerobics and stationary biking.

Like your new eating habits, maintaining an exercise regimen will be a long-term commitment. You don’t have to become a fitness junkie, but you do need to work regular exercise into your daily routine. Even walking on a treadmill for 30 minutes a day will help you shed pounds fast, and keep them off for good. Plus, you will lower your risk of heart disease by improving your cardiovascular fitness. 

If you are considering weight loss surgery, you need to have a complete understanding and acceptance of the changes you will face. This is not the easy way out. Achieving weight loss goals requires dedication, and if you do not believe you can comply with your surgeon’s instructions, then weight-loss surgery may not be your best option.

Dr. Provost attended medical school at UT Southwestern Medical Center in Dallas, Texas, graduating fourth in his class of more than 200 medical students. He remained at UT Southwestern to conduct his residency at Parkland Memorial Hospital and became an Assistant Professor in 1995. Dr. Provost went on to become the Medical Director for the Surgical Management of Obesity at UT Southwestern Medical Center from 2000-2008. He has taught bariatric surgery procedures to hundreds of medical students and doctors and is also a featured medical expert on the Weight Loss Surgery Channel.

Dr. Provost is proud to open a new practice in north Dallas to continue providing expert care to weight loss surgery patients from all parts of the country. His areas of specialization include Lap-Band® and laparoscopic gastric bypass surgery, endoscopic pouch reduction, and revisional surgery for the management of complications and failures of prior weight loss surgery operations. A strong proponent of patient support both before and after bariatric surgery, Dr. Provost’s practice also sponsors regular weight loss surgery support groups.

Qualifying for Weight Loss Surgery

Most insurers adhere strictly to National Institutes of Health (NIH) guidelines regarding weight requirements for bariatric surgery, as determined by your body mass index (BMI). You can calculate your BMI by dividing your weight in kilograms by the square of your height in meters (kg/m2). A BMI between 25 and 29.9 is considered normal. A BMI > 30 defines obesity, while a BMI > 40 represents severe or morbid obesity. Candidates for operative intervention should have a BMI > 40 kg/m2, or a BMI > 35 kg/m2 when associated with high-risk co-morbid conditions. 

The decision to undergo weight loss surgery deserves much thought, a complete understanding and acceptance of the lifestyle and dietary changes resulting from the procedure, and thorough knowledge of the benefits and potential risks of the surgery.  Provost Bariatrics offers monthly information and question/answer sessions for patients who are considering weight loss surgery.

Dr. Provost has experience with a variety of bariatric procedures, but prefers the gastric bypass and the Lap-Band procedures. Should you choose to undergo weight loss surgery, Dr. Provost will explain the expectations, risks and benefits of each course of treatment at your initial consultation. To learn more about these procedures, we invite you to contact our office, or attend one of our upcoming informational sessions.

Restrictive procedures include the vertical banded gastroplasty (VBG) and gastric banding (i.e., Lap-Band®). Both procedures involve creating a small pouch in the stomach, 15 to 30 ml, to limit the amount of food a patient can eat. The Roux-en-Y gastric bypass (RYGB) also involves the creation of a small gastric pouch which is drained by the small intestine. This operation combines gastric restriction with a minimal degree of malabsorption. An added benefit is the limitation on the intake of simple sugars, which cause you to feel ill. Although the Lap-Band procedure has gained popularity since it was approved by the FDA in 2001, the RYGB is still the most commonly performed obesity procedure in the United States.

Dr. David Provost has experience with a variety of bariatric procedures, but prefers the RYGB and the Lap-Band. Both procedures are generally performed laparoscopically in most patients. This means that instead of performing the surgery through a standard incision, typically going from below the breastbone to above the umbilicus, the operation is done through six smaller incisions, less than one inch in length, using cameras and long instruments. More information about the Lap-Band and gastric bypass procedures is available on this site.

Advantages of the Lap-Band include ease of insertion, shorter hospital stay, and rapid recovery from surgery. The risk of major complications from surgery is low with the Lap-Band, as is the operative mortality.  A disadvantage of the Lap-Band is the potential need for re-operation in the future for band replacement or removal, which may be required in up to 5% of patients. Indications for band removal include erosion into the stomach, band slippage with resultant vomiting, and port or tubing leakage. These complications are rarely life-threatening nor emergent, and can be managed laparoscopically. 

We have been very pleased with the results of the Lap-Band, and we believe it is an excellent alternative to the more invasive gastric bypass. Of course, to ensure long-term success, you need to adhere to prescribed eating habits and schedule routine follow-up appointments for band adjustments. For more information about the benefits of the Lap-Band procedure, please contact our office.

In addition to weight loss, many associated medical problems will resolve or improve following gastric bypass.  Adult-onset diabetes mellitus improves in over 90% of patients, with 80% becoming medicine-free, including insulin. Patients can also expect improvements in hypertension and high cholesterol, obstructive sleep apnea, shortness of breath, and other respiratory difficulties, such as asthma. Gastroesophageal reflux (acid reflux) is frequently cured immediately. Although permanent damage to joints that has already occurred is not reversible, patients will often experience significant improvements in mobility and joint pain. Improvement is also frequently observed with leg swelling or venous stasis disease, urinary incontinence, and headaches.

As a surgical procedure, laparoscopic gastric bypass has much lower rates of incisional hernia and wound infection, reduced pain, and a more rapid return to work and normal activities than the traditional open-incision gastric bypass.  Some patients may not be candidates for the laparoscopic approach to gastric bypass due to larger size or large abdominal wall hernias. Prior abdominal operations, such as cholecystectomy (gall-bladder removal), hysterectomy, Caesarean section, and appendectomy do not usually preclude laparoscopic RYGB.

For more information about the benefits of gastric bypass surgery, please contact our office to schedule a free consultation.

Bariatric surgery will alter your eating habits dramatically, particularly in the first few months after surgery. To gain the greatest benefits of the surgery, Dr. David Provost recommends patients follow a simple formula:

3 x 3 + 30

What this means is that you should only eat three bites of food at each meal, and separate each bite by three minutes. In addition, you should not drink anything—including water—for at least 30 minutes before you eat and 30 minutes after you eat.

That may sound like a ridiculously small amount of food, but the truth is, after weight loss surgery, you won’t want to eat any more. Both the Lap-Band and the gastric bypass restrict the amount of food that you can fit in your stomach. If you try to eat more than your stomach can hold, you will feel extremely uncomfortable and you may even vomit. In addition, waiting at least 30 minutes after drinking liquids before a meal and also waiting 30 minutes to have a beverage after you eat will help ensure that you get enough nutrients and keep you from cheating your surgery by washing down your food through your pouch.

Finally, slowing down your eating will also let you experience your meals in a whole new way. When you wait three minutes between bites, you have the chance to savor your food, and also appreciate the people who may be sharing the meal with you. So, remember 3 x 3 + 30 at each meal will promote rapid weight loss and help you achieve your goal weight faster than you ever thought possible!