Emergency gastric band adjustment  

The information on this page is designed to guide clinicians as to the most appropriate technique and equipment to use if faced with a patient who requires urgent decompression of a gastric band because of food or fluid intolerance.

Gastric bands are designed to restrict food intake. However, even when a band has a stable history, acute changes can take place leading to the distressing symptoms of severe fluid and food intolerance. It is vital that the correct equipment and technique are used to correct this problem. Bariatric surgery is rightly regarded as a specialist practice but band adjustment is a simple procedure well within the skill set of even the most junior clinician. This guide has been prepared to guide those who do not have experience to deal with the situation safely and confidently. Following this approach will minimise risk to the patient and to the band and will hopefully remove any uncertainty about how to proceed.

It is in essence a guide to help clinicians extricate these patients from a most upsetting situation. Subsequent referral to a bariatric surgeon can take place and the longer term management refined.

The top image on the right shows a demo band positioned on the anterior abdominal wall overlying the actual band placed under the skin. The orientation is set to show a typical arrangement. The patient's head is towards the top of the picture and the band tubing runs from the port along a subcutaneous tunnel before passing through the abdominal wall (usually at the site of the left upper port incision) and into the peritoneal cavity. It is important to try to ascertain the configuration prior to using any needle and thus minimise damage to the system.

   

How I do it ... - follow these steps and you will achieve an accurate and safe band adjustment and you will also have an extremely grateful patient.

Finally before we get to the technique - if successful empytying of a band system does not resolve the problem - suspect a band slippage. This is a serious complication and requires urgent management by an experienced laparoscopic or bariatric surgeon.

Locate the port - usually in the lower midline epigastric port position in patients operated onby me. Other surgeons may use other positions. Dogma based medicine holds this to be the best....! Do this before you scrub and don the sterile surgical gloves. You will then be able to clean the appropriate area after all the other sterile preparation is done.

Equipment: You will need a non coring Huber needle. This is essential to avoid damaging the port beyond repair! If you do not have one - try respiratory medicine or oncology - they often have patients with portacath devices and use these needles. You will also need a 3 way tap and appropriate syringe. If you plan to completely empty a band - use a 10ml syringe. For small adjustments -2 or 5ml syringes allow more accuracy. Use sterile saline to prime the system. I use a standard dressing pack, take the swabs off to one side of the sterile field and use the gallipot for saline. Use the swabs for skin antiseptic. This procedure must be carried out aseptically. You do not want an infected band on your CV. The local bariatric surgeon will fall out with you - big time!
       
Before allowing the syringe to get wet - mount the 3 way tap and secure it. Then prepare to draw up a few ml of saline simply to get all of the air out of the deadspace and maintain accuracy. Draw up some saline before mounting the needle. Get rid of the air in the deadspace. Lock the tap!
       
Clean the skin. Fix the port between two fingers of your non dominant hand. Make an approach perpendicular to the palpable surface of the band port. You can often feel the ridge surrounding the silicone component. This will help you hit the target. Carefully note the amount of fluid in the syringe before opening the tap. The band will often deflate into the syringe without any initial need for aspiration on the plunger.
Remove the required amount. See discussion below. Lock the tap before removing the needle from the port. Apply a small dressing. This will keep the evidence of haemorrage off the patients clothes and avoid alarming the other patients who are in the waiting room! Different bands have different structural and dynamic characteristics. Some are easy to feel. European surgeons are noted for placing the port deep in the abdominal wall and sometimes radiological guidance is required to gain access.
If you are stuck call me for advice. Details are available on the Contact page. Back to bariatric surgery page. Back to the gastric banding main page. Home page.
       

The amount of fluid to remove will depend on the circumstances. Whatever the amount - make a careful record in the patient's notes. In an urgent setting there is a good case to simply remove all the fluid from the system. If the patient has had an adjustment to increase the restriction withoin the previous 36-48 hours and has then developed obstruction it is sometimes worth removing 50% of the amount added at the last adjustment. If that does not solve the problem it is probably wise just to empty the band, record the amount and refer the patient back to their surgeon or bariatric nurse specialist.