Due to the possible correlation between early vomiting and gastric prolapse [1, 2], patients are placed on a diet that progresses from liquids to solids over the first 6 weeks after surgery. For weeks 1 and 2 the diet is thin liquids—any fluid that is thin enough to go through a straw. For weeks 3 and 4 the diet is pureed foods—foods that do not need to be chewed, as if the patient did not have teeth. For weeks 5 and 6 the diet is soft and flaky solid foods and crunchy foods, specifically excluding dry/tough chicken, overcooked steak, and doughy bread, which tend to form a large bolus that cannot traverse through the narrow band stoma. Patients are counseled to eat very slowly, chew their food thoroughly, and to avoid eating and drinking simultaneously, as to not outpace the emptying of the food through their band, which if occurs will result in regurgitation or vomiting.

Nutritional deficiencies have not been reported after LAGB, perhaps because the operation is purely restrictive. However, patients are encouraged to take a fortified daily chewable or liquid multivitamin. More importantly, patients should already have the nutritional knowledge and skills to make healthy food choices before any bariatric surgery, including LAGB. Patients are told that high-calorie liquids and soft foods, such as chocolate and ice cream, are physically easy to eat but will lead to weight regain or weight loss failure.

The most important dietary counseling that LAGB patients need is how to eat—slowly and chewing thoroughly. They must learn how to put the fork down between bites. Most importantly, they must recognize when they are full, and then stop eating. This is a new skill for morbidly obese patients. Even an extra bite will make them regurgitate. Counseling on social eating and food choices is greatly appreciated by patients, since this is usually their greatest source of anxiety, particularly in young adults and teenagers as they start dating. Diurnal variation in esophageal motility may play an important role in dysphagia and appears to vary according to time of day and amount of emotional stress. Dysphagia is common when patients are eating in a stressful situation, mostly because they are typically distracted and have eaten quickly without chewing. They are counseled to have a yogurt, soup, or a protein drink during stressful times. Breakfast is sometimes difficult; therefore a liquid meal is encouraged.

The mechanisms by which LAGB works include decreasing appetite, creating satiety with a smaller amount of food, and behavior modification [3]. This is a direct function of a small gastric pouch (10–15 mL) and a narrow stomal opening that slows gastric emptying (12 mm). The LAGB acts in this capacity through external constriction of the stomach, which is gradually tightened in accordance with each individual’s needs. If no constriction is created, no satiety is reached, and no weight is lost. Therefore, weight loss after LAGB is contingent on band adjustment. The band is useless if adjustments are not performed. Both patient and surgeon must understand this; otherwise weight loss will be suboptimal, the operation ineffective, and the surgery a wasted effort.

The band is left empty when initially placed. The first adjustment is performed 6 weeks postoperatively. This allows time for a capsule to form around the band and makes its position around the stomach more secure. Adjustments should be made while patients are eating solid food. The band is meant to work with solid food, specifically to maintain stretching of the gastric pouch to create an early sense of satiety. An appropriately adjusted band also acts as an appetite suppressant. A sense of hunger, increased appetite, and increased snacking are signs that the band is not appropriately tightened. Soft and liquid foods empty faster than solids, and thus more can be ingested before the feeling of satiety is reached. Thus, a band that is too tight will make solid food ingestion difficult, but easy for creamy sugary liquids. This is an example of maladaptive behavior and may necessitate band loosening.

There are two general strategies to band adjustment: in-office adjustment using a clinical algorithm and radiographic adjustment under fluoroscopic guidance. Each has its advantages and disadvantages. In-office adjustments are quick and inexpensive, but require frequent visits due to inaccuracy of the adjustment. Radiographic adjustments are more cumbersome and expensive, but require fewer visits due to the more accurate adjustment visualized under fluoroscopy.

The maximum recommended amount of saline that a gastric band accommodates depends on the band type. The Lap-Band System™ (Allergan, Irvine, CA) comes in five different types of bands which hold various maximum recommended volumes as shown in Table 1. Similarly, the Realize™ Band System (Ethicon Endosurgery, Cincinnati, OH) comes in two types and sizes. In addition to maximum recommended volume capacity, Table 1 shows the typical average volume range where a patient would eventually be when optimally adjusted.

There are two aspects to band adjustments: locating the access port and determining the volume of saline to be used. When the procedure is performed in the office, the port is located by palpation. The band is adjusted by percutaneously accessing the port with a non-coring needle and subsequently injecting sterile saline, which tightens the band. Withdrawal of saline results in band loosening with subsequent decreased restriction. The skin is cleansed with alcohol, and a non-coring needle on a pre-filled syringe filled with the desired amount of saline is introduced through the skin into the access port (Fig. 2). Successful port access is confirmed by feeling the needle hit the metal base of the access port and having free reflux of saline back into the syringe. Use of any needle other than a non-coring needle may result in damage to the access port septum and subsequent leak of saline. Local anesthetic is unnecessary, as it is more painful than the needle itself. Having the patient lie on the examination table and lift his or her head up off the examination table while tensing the abdominal muscles can assist in feeling the port. Sometimes having the patient stand up will use gravity to drop the pannus and make the port more apparent.

Locating the port can be challenging in patients who have a large amount of subcutaneous fat, particularly women and individuals with a body mass index (BMI) greater than 60. An extra-long needle may be necessary to reach the port. An X-ray can be obtained to localize and mark the port (Fig. 3). The learning curve for port localization using palpation is surprisingly long and may take up to 100 cases. Our experience has shown that on review of our first 200 consecutive gastric band patients (69 % female, mean BMI 48.7), 660 adjustments were performed in the office (74 % by a nurse practitioner and 26 % by a physician) [4]. Twenty-eight (4.2 %) adjustments were unsuccessfully performed by a nurse practitioner and required physician assistance. Twelve of those attempts (1.8 %) on nine patients required radiographic guidance to localize the access port. All nine patients were women who were in the first 75 patients adjusted.

The decision to tighten, loosen, or leave the band alone is based on three variables: hunger, weight loss, and restriction. A properly adjusted band induces the lack of hunger and appetite suppression. It should also induce a prolonged sense of satiety that lasts longer than 2 h after a meal. Weight loss should be constant and gradual over the course of 18–36 months.

The goal rate of weight loss is 6–10 lb/month. Lack of weight loss reflects too large a portion intake, and suboptimal satiety and hunger control, indicating the band needs tightening. The Green Zone chart (Fig. 4) [5] is an invaluable visual chart which educates the patient on the role of the band as a tool towards weight loss, and involves the patient in the decision-making process towards band adjustment. As shown, the Yellow Zone describes the patient as hungry between meals, eating large portions and not losing weight. The patient in the Yellow Zone requires an adjustment to move him/her towards the Green Zone which represents the optimal situation: good appetite control, satiety with small portions, and weight loss. A patient in the Green Zone requires no band tightening or loosening. However if a patient experiences night cough, frequent regurgitation despite eating very slowly, and subsequent maladaptive eating of high-calorie soft foods, then he/she is in the Red Zone and needs to have the band loosened. Having a large framed poster of the Green Zone in the exam room is very helpful and an excellent investment towards patient education and care. It is also important for both clinician and patient to understand that the band can be adjusted at any time throughout the lifetime of the banded patient, and is not limited to a certain amount of time since surgery. For example, if a patient has been in the Green Zone for 5 years, but progressively develops increased hunger, he/she can have an adjustment in order to return to the Green Zone.

The amount of saline to inject when the patient is in the Yellow Zone is based on experience based on trial and error. In order to provide a template for new clinicians, a clinical algorithm was designed at NYU and is used as a basic general guide to use for the 9.75 cm LAPBAND SYSTEM (Allergan, Irvine, CA) (Table 1) [6] which holds a maximum recommended capacity of 4 mL. With experience, the clinician can modify this algorithm in regard to volume of saline added, particularly depending on the type of band the patient has. For example, in a band with 10 mL maximum recommended capacity, the first adjustment may be 3 mL, with subsequent increments of 1 mL.