ASMBS Statement for Access to Care for Obesity Treatment
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Our office is open from 8:00 am to 5 pm Monday through Friday. We do not use automated answering machines and we take calls through lunch hour. We will usually be able to confirm eligibility on the phone. Our staff will be able to answer questions and we work hard to set up consultations in a timely manner.
As bariatric procedures become more common, all physicians will need to be aware of potential complications. It is important to recognize some of the warning signs and be familiar with how to diagnose and direct treatment. The following outline will give you some general information but it is important to contact us right away if you have any question or doubt. We provide 24-7 coverage for our band patients.
In general, band complications are uncommon and relatively easy to manage. This is one of the distinct advantages over other bariatric procedures such as gastric bypass. We monitor patients for these problems at their follow-up visits, however we recognize that patients will often contact their primary providers first. This summary will give you an overview of potential problems.
Vomiting should not be considered an expected side effect of gastric banding. It is usually caused by eating too fast, too much or a band that is too tight. Most of the time, this can be corrected by slowing down eating or simply removing a small amount of fluid in the office.
Band slippage occurs when the band migrates too low on the stomach.
At the time of surgery, the band is placed just below the gastro-esophageal junction. When the band slips, patients can develop reflux, pain or vomiting. In rare circumstance, the stomach can become ischemic so it is important to refer these patients in a timely fashion.
Traditional slip rates are approximately 10%. Our published slip rate is 2%. We believe this is due to improvements is surgical technique, the recognition and repair of hiatal hernias at the time of band placement, follow-up strategies and improved band design.
Signs and Symptoms
Patients with slips usually present with vomiting, night time reflux, food intolerance or pain.
The first thing we do with any patient who has the above symptoms is to remove fluid for the band. The band can be accessed percutaneously in the office. This requires specialized needles and technique therefore I would dissuade you from trying it in your office. We are available for this 24/7.
If this fails to relieve symptoms, the next text is an esophagram. This will quickly and safely diagnose a slip. EGDs are not indicated in this setting and could be harmful.
Slips are repaired surgically. They can almost always be done laparoscopically. The repair involves placing the band back into the desired position and anchoring it with sutures. Most patients will stay one night in the hospital and return to activities within a week.
Port problems occur in approximately 3% of patients. Similar to infusaports, these devices may develop mechanical problems such as leaking saline. This is not dangerous to the patient but will impair weight loss. The treatment is port replacement which can be accomplished as an outpatient with minimal risk.
Many people ask if the band can erode into the stomach. The band is a foreign body and these complications have been reported. They are quite rare and occur at a rate of <0.05%.
Signs and Symptoms
Since this process occurs slowly, a fibrinous capsule forms around the band. Peritonitis is an uncommon presentation and most erosions present either with loss of satiety and weight gain or cellulitis around the port.
Erosions are diagnosed by EGD. This is probably the only role EGD has in the work up of band complications.
Our recommendation is that all eroded bands be removed with a laparoscope and the patient should wait six months for band replacement.
Many insurance companies require a six month period of non-surgical weight loss. Some of our colleagues prefer to manage that period themselves. Others would rather have us handle it. For this reason, we have developed an evidence based six month program using current NIH recommendations. This covers a six month period and addresses the pathophysiology of obesity, its risks and treatment options. It also includes dietary evaluation, psychological evaluation, and counseling in healthy eating and exercise. We utilize one-on-one and group sessions during the process. We do not prescribe weight loss medications nor will we change any treatment plan that you have initiated. Most but not all insurance companies will accept this as the six months of medical management.
Weight loss after any bariatric procedure is highly variable. Patient compliance is paramount. However, the long term result is quite similar among the major procedures, i.e. gastric band, roux-en-y gastric bypass and the sleeve resection.
Weight loss after surgery is expressed as a percentage of Excess Weight Loss (%EWL).This is more useful than expressing weight loss in pounds or kilograms since patients start at different weight and may need to lose different amounts. For example, a patient who starts at 230 pounds may only need to lose 50 or 60 pounds. A patient who starts at 350 pounds needs to lose much more.
We report an average long term weight loss of 60% EWL. This compares very favorably with other published reports. Bear in mind that this is a slow, gradual process. Gastric bypass patients may lose dramatic amounts of weight in a short time but weight regain is a problem. Long term weight loss after gastric bypass in the literature is 50% EWL. Remember that it is not our goal to make patients skinny but to make them healthy.