The band functions as a restrictor or high-pressure zone that is placed distally to the GE junction. When the procedure is successful, the patient will be satisfied by eating a small portion of food that will stay above the restrictor for several hours and then pass through the digestive circuit allowing the patient to be satisfied with less food and achieve weight loss. In our experience with laparoscopic adjustable gastric banding, the patients that successfully lose weight with the band are satisfied with smaller portions after inflation of the band; however, other patients remain unsatiated despite the restriction and resort to maladaptive eating patterns. Many caregivers ascribe such treatment failures to noncompliance; however, some patients may fail this therapy because of lack of hunger suppression. To date, research has shown no reduction in the hormone ghrelin, considered the primary hormone involved in hunger, with gastric banding [4].

During the early postoperative period after the band is placed, it is usually not filled. Despite this, many patients still experience early satiety in the immediate postoperative period. This is probably due to the inhibition of receptive relaxation following eating. Patients are told to adhere to a liquid or mush diet for their first 3 weeks following surgery. This diet allows the band to scar into place, reducing the risk of movement, slippage, or gastric prolapse. Rarely, an acute slippage can be found. The hallmark of an acute slippage is inability to tolerate liquids and an abdominal film demonstrating change in position from the 1 to 7 o’clock position normally seen following laparoscopic adjustable banding to a 3–9 o’clock or horizontal position; rarely, the band may rotate up to 180° [5]. In over 1,000 adjustable bandings, we have only seen one case of acute slippage. Following the clear liquid phase of diet, patients are advanced to solid food. We recommend that adjustable band patients obtain a food scale and weigh their food, with the ideal portion size being 4 oz of solid food. If patients are not satiated with 4 oz of food after progressing to a diet of regular consistency, we will begin adding fluid to the band. Generally, we fill the bands on a gradual basis seeing the patients on at least a monthly basis until they achieve restriction. Once a reasonable amount of fluid is placed into the band, an upper GI series is performed to make sure that the anatomy correlates with the patient’s symptoms. Alternatively, the balloon can be filled under fluoroscopy.

Numerous filling schedules have been proposed; most of these aim to modify the amount of fluid in the band until the patients experience satiety with small food portions. In our experience, the symptoms experienced by the patient do not reliably correlate with the degree of filling nor necessarily indicate pathology related to the band. When patients have heart burn, regurgitation, or inability to tolerate oral intake, abdominal films will often show that the band is too tight and there is some dilation of the esophagus or the concentric pouch. However, the absence of hunger suppression and a satisfaction with a small amount of food are not reliable indicators that the band requires more fluid. It is therefore essential in the postoperative management of band patients to correlate X-ray imaging or fluoroscopic imaging with the patient’s symptoms and not rely only on history to determine adequate titration of the band.

While the advantage of laparoscopic adjustable gastric banding is reduction in serious complications immediately following the surgery, there is an increased risk of requiring revisional procedures. The revisional surgical rate for laparoscopic adjustable gastric banding has been estimated approximately 5% per year [3]. Complications necessitating revision include issues with the port, poor tolerance of oral intake, esophageal dilatation, gastric prolapse, concentric dilatation, or inadequate weight loss.

One of the most common issues that patients will present for endoscopy or will be seen by an endoscopist following LAP-BAND surgery will be symptoms of reflux or regurgitation. In the initial postoperative period, there is actually a reduction in GERD-type symptoms in patients that receive laparoscopic adjustable gastric banding. This is due to the fact that the hiatus is probably repaired in many patients during the surgery. The band itself can function as a prosthesis preventing regurgitation; furthermore, with weight loss, abdominal pressure is reduced, lowering reflux. GERD-type symptoms are very common in patients with obesity because of the increased abdominal pressure of the abdomen, and this actually leads to reflux symptom, similar to what is seen in pregnancy. Thus, the reappearance of reflux symptoms after they have been alleviated by weight loss usually indicates the presence of acid producing cells above the band. Many physicians prescribe proton pump inhibitors, and we think that this is fine to reduce the symptoms of esophagitis. However, the primary treatment for GERD symptoms following laparoscopic adjustable gastric banding should be relaxing of the band and making sure that there is no evidence of gastric prolapse or slippage [3].

In the postoperative management of band patients, it is essential to understand the physiology of bands. The band creates a potential high-pressure zone with the pressure increasing with fills. The esophagus therefore must create higher pressure during peristalsis to have food pass the lower esophageal sphincter and then through the band. The silicon is inelastic and will not stretch; this can create a problem if the band is overfilled or if the patient eats more than prescribed portions. Patients who attempt to eat more than the prescribed portions can cause emesis. Long term, the patient’s pouch or even their esophagus can dilate, causing regurgitation and reflux symptoms. Another possibility is the pressure causes the band to move causing a prolapse or chronic type of slippage. It is therefore essential to educate patients to monitor the amount of food that they take by weighing their food. In addition, the presence of new onset GERD, regurgitation, or an increase in the ability to be able to tolerate food as well as a decrease in the ability to tolerate food should prompt radiological imaging. The preferential exam is an upper GI series. Use of endoscopy is required to determine the degree of esophagitis. Only an endoscopist with considerable experience can ascertain the position of the band.