NaNa

This is nothing out of my mouth, but by the surgeon who created the green zone...just wanted to let you know that. The article is attached in my first post, please read though it. Many US surgeons follow the Green zone chart and fill protocols to prevent lap band complications, sure some US surgeons don't follow this, but I can't argue that the US has a very high complication rate.

Debbie,, That area just above the band is called the lower esophagus, which if food sits there all the time can damage and stretch your esophagus, THE AREA ABOVE THE BAND IS NOT THE STOMACH, but the esophagus -- THERE IS ONLY ONE TYPE OF PROPER BAND INSTALLATION. This photo is curiosity of the surgeon who created the Green zone, and depicts the esophagus being stretched with food sitting there for long periods of time -- which many US surgeons follow to prevent long term band complications. Edited to add: Many BAD lap band surgeons follow gastric bypass rules, of the Pouch which WE DO NOT HAVE, and have the patient follow Bypass rules of not eating and drinking at the same time. You can still lose weight with a proper adjusted band with drinking and eating, if your band is adjusted properly. Here is a link to the dilated esophagus http://bariatrictime...ads/obrien4.jpg

My first surgeon's office told me that too over 8 years ago -- and THAT WAS WRONG INFORMATION FOR ME -- HENCE why I have a brand new lap band and new surgeon today.

I think breaking your surgeons rules ARE THE RIGHT THING TO DO -- IF YOU DON'T WANT LONG TERM COMPLICATIONS. I think a lot lap banders ARE MISLEAD --- I've come to realize that WE ARE SUPPOSED TO DRINK WITH OUR MEALS to push the food through from the esophagus into the stomach...I THINK MOST US SURGEONS ARE MISLEADING THEIR PATIENTS -- into a dilated esophagus.

I know the band is placed in "different" positions on each person and everyone will have different experiences based on how their surgeons placed their band. SOME SURGEONS DO PLACE THE BAND WRONG -- I've known many that say they can't eat most solid food and vomit daily, however I've had 2 lap bands and I've always been able to eat solid food WITHOUT vomiting with both bands as long as I was in the green zone, and my older 4cc band was "high pressured" and very tight out of the gate. So there IS EVIDENCE of many people having esophageal dilation from letting the food sit in the esophagus too long and in fact if done over many years it can actually cause a "second stomach" in the lower esophagus. So please DON'T confuse others by saying "there is actually a pouch" when IT IS NOT. AND LAP BANDERS SHOULD NOT HAVE A POUCH-- THIS HAS NOTHING TO DO WITH WHAT YOUR SURGEON SAYS.

I thought I would post this topic because it may help others and I wonder if others are still waiting for hours to drink after they have eaten their food. Someone just made a post about not drinking up to a certain time after eating. Just think about it, if you "wait" and NOT wash the food down, it is actually sitting in your esophagus, "stretching" it over time, we lap banders do not have a pouch -- like Bypass people do, although we have called it that in the past, the band actually makes a little area above the banded stomach which is actually the lower esophagus. Well there is a LOT of misinformation going on now about not drinking and eating at the same time. When I got my band over 8 years ago, we were given the 30/30 rule to drink up to 30 minutes before a meal and not drink until after 30 minutes after we ate. NOW -- based on new evidence that MANY lap band surgeons and nutritionist are not aware of is waiting to drink IS NOT ADVISABLE - BUT CAN IN FACT CAUSE LAP BAND COMPLICATIONS. Could this be why the lap band complication rate in the US is so high? Could be, there is evidence by the most skilled lap band surgeon who created the green zone that waiting to drink will actually CAUSE esophageal dilation because the food must be washed through each time we eat and NOT sit in the esophagus causing to stretch, FOOD should always pass through the band and not sit for hours or days inside esophagus. Also I do find that if I eat and drink with my new band, I still get satisfied. Also if we can't drink right after taking a bit of food without vomiting the band is too tight, food and liquids should always go past the band. Please read this article on this subject in its entirely, I also gave this article to my own surgeon for him to review it because MANY US surgeons follow the Green zone chart to prevent complications with the band. One of the key lessons learned from Burton’s studies was that each bite of food should pass across the band completely before another bite is swallowed. There is no pouch or small stomach above the band and there should never be food sitting there waiting. http://bariatrictime...1/#comment-2133 Gastric Banding and the Fine Art of Eating

Well there is a LOT of misinformation going on now about not drinking and eating at the same time. When I got my band over 8 years ago, we were given the 30/30 rule to drink up to 30 minutes before a meal and not drink until after 30 minutes after we ate. NOW -- based on new evidence that MANY lap band surgeons and nutritionist are not aware of is waiting to drink IS NOT ADVISABLE - BUT CAN IN FACT CAUSE LAP BAND COMPLICATIONS. Could this be why the lap band complication rate in the US is so high? Could be, there is evidence by the most skilled lap band surgeon who created the green zone that waiting to drink will actually CAUSE esophageal dilation because the food must be washed through each time we eat and NOT sit in the esophagus causing to stretch, FOOD should always pass through the band and not sit for hours or days inside esophagus. Also I do find that if I eat and drink with my new band, I still get satisfied. Please read this article on this subject in its entirely, I also gave this article to my own surgeon for him to review it because MANY US surgeons follow the Green zone chart to prevent complications with the band. One of the key lessons learned from Burton’s studies was that each bite of food should pass across the band completely before another bite is swallowed. There is no pouch or small stomach above the band and there should never be food sitting there waiting. http://bariatrictime...1/#comment-2133 Gastric Banding and the Fine Art of Eating

You mentioned: There is nothing wrong with debate by any means between the different types of surgeries. It's all about keeping it civil and constructive, not destructive. Unfortunately, that is the problem, members NOT keeping the debates "civil" I have seen on Obesity Help where people were actually sent to JAIL, members were harassed OUTSIDE of the forums, bullied etc, so this type of behavior is very concerning to members who want a SUPPORT system in place where they can come to post in "peace". Ideally, in a "civil" debate you post "facts" about each surgical type backed up by studies, but unfortunately in a lot of cases, that does not work. Yes, the online bullying can get real and scary, when it should never get that out of hand, but I've seen it band bashing and bulling get real ugly and out of hand, that's all I am saying.

You mentioned: Do not stoop to the band bashing level... That's wishful thinking I think what should happen to AVOID conflict where we can ALL GET ALONG PEACEFUL IS.. For Alex, to BAN -- POSTS like "Band vs Bypass", "Band vs Sleeve" and "Why did you pick the Band over Bypass or Sleeve" I think these types of posts are triggered to CAUSE CONFLICT, I think those who are truly here to HELP others with their own type of surgical type, and truly here for "support" SHOULD STAY AWAY from these posts and Alex SHOULD BAN THEM, and direct those who are researching a surgery type to research this outside of this forum or have Alex to PIN Pros and Cons to each type of surgery and point these newbies to these types of posts......then this NEW forum should work out great.

Congrats! Reaching goal is a good feeling.

Please read this article in its entirety before you add more saline in your band, please learn how the band WORKS before you add any more saline. Getting food stuck OFTEN should be a warning to you and the LAST thing you need is to add more saline, if you can't or is not willing to chew your food well. Sometimes, when you come to a plateau, you should examine your eating and exercise habits, your calories should be low, Water should be over 8 glasses per day and exercise should be at least 1 hour per day, instead of adding more saline, MORE SALINE Is not always better especially if you are already in the green zone, also if you are getting food stuck often you maybe already in the red zone and may need to get a little saline removed. And lastly -- the band will NEVER stop you from eating, it helps you stop, if you are dealing with head hunger the band can't stop that, many people seek counseling for that, the bands job is help reduce hunger NOT stop you from eating. Last thing...the lap band has a VERY high complication rate from people getting food stuck often and staying in the red zone too long and vomiting frequently, so please remember that. http://bariatrictime...1/#comment-2133 Gastric Banding and the Fine Art of Eating Good luck

You mention: My own research has led me to believe that Gastric seems to result in more weight loss than LapBand You are correct, overall the Gastric Bypass is DESIGNED for quick weight loss due to the malabsorption, and overall MORE Bypass people lose quicker and more weight loss than Lap band patients. So you SHOULD NOT COMPARE the Lap band and Bypass in terms of weight loss because they are VERY DIFFERENT PROCEDURES. However, Many lap band patients DO lose as quicker and as MUCH as any Bypass patient IF they go into this focused, exercise daily and eat a very low calorie, low carb diet. So in other words, you have to WORK YOUR BAND HARD to get the same results as a Bypass patient in the first year, some people have stronger metabolisms than others so each banded person results will differ, also if you start off very heavy, you will lose quicker with the band anyway, the smaller you are with ANY weight loss surgery the slower your weight loss will be. Also many don't choose the Lap band over the Bypass because of "FAST" weight loss, many choose the Lap band because they DO NOT want to deal with life time problems of malabsoprtion, dumping syndrome and hypoglycemia long term. Also, after about 2-3 years after the Bypass the malabsorption of calories STOP and MANY bypass people gain back weight, and MANY NEED the Lap band over their bypass LONG TERM to maintain that weight loss, you can google or research that, and even tho they can easily gain back weight due to a stretched pouch, they STILL HAVE TO TAKE Vitamins and can have Vitamin deficiencies for the rest of their life.

Exactly -- she flat out knew she was abusing her band and came clean, "many don't come clean" they just say the band "liked to killed them" without a explanation "why". Honestly, I respect those who abuse their bands and tell the truth, I had a friend a few years ago abused her band and she did not lie about it, she kept it way too tight and vomited many times per day, she got very skinny, but sadly she lost her band, she is not upset about, it was just "her method" to get thin, however, you can't do this with the band and expect to keep it forever.

From personal experience and studying the lap band carefully and seeing others report pouch dilation -- NO you CANNOT dilate your pouch on a loose band. However, if you vomit a LOT before your band heals in the first 6 weeks to a few months post op, YOU can slip your band, even with hardly no saline, there are different types of slips, the sutures can come loose, or the stomach can prolapse over the band, very large pouch dilation. Also surgeons technique can greater your chances of pouch dilation, if the surgeon installs the band incorrectly, this can also cause pouch dilation. Because when the band is loose there is NO TIGHT PRESSURE there to dilate, inflame and irritate the stomach. However, this is the tricky part, 'some' people have very tight bands with little to no saline, hence it could be a bit too small for their anatomy. I will put it this way, if your band is loose -- NO you cannot stretch your pouch, pouch dilation ONLY happens when your band gets tighten either too tight or to the Green Zone. Pouch dilation usually occurs when the band is TIGHTLY RESTRICTED, and you eat TOO MUCH FOOD CONSTANTLY ON A TOO TIGHT BAND, and when too much food is forced upon a VERY tight created pouch above the band, it has no where else to go but either expand your esophagus (which is called esophageal dilation, or expand your pouch, which is called mild slippage, pouch dilation). This is why many people who WANT TO EAT MORE FOOD, get saline removed to prevent from stretching their pouch, however if you get an adjustment that is in the RED zone(too tight), this will greater your chances of pouch dilation quicker than in the Green zone even if you don't eat much food. You also can dilate your pouch in the Green zone if you constantly eat too much food and vomit daily, which leads to reflux, heartburn, frequent vomiting and slippage. You have to be EXTRA careful with chewing your food and not over eating once you get into the Green zone to prevent pouch dilation.

Yes, you have to use the band as a tool and not a bulimic device. SkyMoon's lap band probably had slipped for YEARS and she probably lived with a mild slip band for years before it got severe. She was pretty much at the END of her lap band when she suffered horrible complications. Many THINK they can PB and vomit often with NO consequences, I am sure SkyMoon's band had slipped WAY before she had all this horrible vomiting, she only reported the horrible END OF IT, not necessarily what lead up to the horrific vomiting that she was doing (which I am sure keeping her band too tight and vomiting frequently) IT TAKES A WHILE BEFORE HORRIBLE SLIPPAGE TO HAPPEN -- it just does not happen overnight. I've heard worse, the only thing is I thought it was only possible to vomit 50 times a day based on others who've abused their bands admitted doing, and MANY DO, SkyMoon is not a rare case...I AM SURE MANY ON THIS VERY FORUM DO THE EXACT SAME THING IN PRIVATE. I guess SkyMoon broke a record with vomiting 60 times a day , her video is just a PRIME example of Lap band abuse revealed in your face and the consequences of it.

Thanks Alex! You and I are old school bandsters so I am sure you know what I am talking about. I am eagerly awaiting for the new changes!

Well if you plan on "abusing" your band and keeping it dangerously too tight, and intend to lose weight by vomiting all your food daily and have no respect for how the band is supposed to work, I would seriously advise you to NOT get the band. The band can be very safe if it is installed properly, and you follow safety fill protocols. Vomiting with the band should be a VERY RARE mistake. Some people will get the band and use vomiting as a "sport" and Pb on purpose, and disregard eating rules with the band since you can easily bring up food once the band gets tighten to the green zone, if you don't chew well, or eat too much. You can DAMAGE the band by not chewing your food well and vomiting daily, or keeping it too tight, it's just that simple, YOU choose your destiny with the band in most cases, REAL complications are rare and preventative complications are HIGH. Please take the time and read this article on how the band SHOULD work, and you don't have to worry about anyone else's band problems as long as you do what you are supposed to do and your surgeon installed it properly. This is the best article yet on how to live with your band and how to avoid complications, read it well and follow it and you will do well. Good luck http://bariatrictime...1/#comment-2133 Gastric Banding and the Fine Art of Eating

Hi Alex, Thanks for the exciting news! However, I have some serious concerns. Combining ALL surgical types can backfire. The reasons many lap banders come here now is that they feel this is a 'safe haven' from Lap Band bashing. The Lap Band forum on Obesity Help has been destroyed by "The Other Type" of surgeries and those who've had complications or their bands removed and "moved on" to "other weight loss surgical types.. And sadly NO ONE goes to the lap band forum on Obesity Help any longer due to all the negativity and if this new venture is not planned out carefully and there is not "heavy" moderating, it may turn into the same thing. I know you mean well, and ideally if everyone CAN GET ALONG, this will be a wonderful idea. But again, I've seen Lap banders bullied for years and while I am hopeful, I am concerned about lap banders getting the support they need without constant bickering. I try to come here to bring "value" and get support and try to stay on track with my weight loss and help newbies, I don't have time to come here and bicker about I am stupid for getting the band and it will be soon to be removed..just saying An excited, but concerned member

Also...will the new site have the following functionality?: 1. A Block button that actually works where the person that you've blocked can no longer see your posts or respond to your posts. 2. The capability to make your profile private 3. The capability to upload pictures "privately" Thanks

Your welcome ! And congrats on the green zone! And happy losing.

I agree with ButterFly -- YOU are in control of how tight your band should be, always remember that, they work for you. You should let them know how tight you want your band, when they are filling your band under Flouro -- you can still let them know if they should back off the saline, or add more.

There is really no need to see your surgeon after the first year especially if you are in the Green Zone and KNOW what danger signs to look for. Many band patients are not skilled enough to know "warning" signs with the band or many band patients IGNORE them. But if you are on TOP of lap band warnings, such as "able to eat too much", OR the band gets extremely tight with no recent fill adjustment, frequent vomiting, frequent reflux at night, and a dry frequent cough, -- you really don't need to see your lap band surgeon but once per year, or six months. I agree if it ain't broke don't fix it, congrats on your success!

Please read this article of how the band SHOULD WORK. Also you just made a post about "Burping" which indicates you could be too tight. There is sometimes a fine line between the Red zone and Green zone. You should NOT be burping up air and food if you are truly in the Green zone. If you are very excited about your new adjustment and seeing the scale move -- please don't let that excitement overrule your band being too tight. Because that excitement can turn into horror. Remember it's YOUR BAND and YOUR BODY, if you damage your band, you will have to pay for it, or have to eventually get it removed. Being in the Red zone too long comes with horrible consequences and will lead to band damage and removal, please remember that. I have highlighted in RED what a too tight band indicates in this article, and highlighted in GREEN what the green zone feel like. You can IGNORE this article and keep your fill level even if you are in the Red zone, but that will be all on you if you suffer complications, you have been far warned. Also remember constant burping, dry cough, and not able to eat solid Protein without pain an vomiting, and throat irritation, usually are the first sign that you are too tight after a recent fill. But if you are in the Green zone by reading this article, congrats and good luck on losing! Gastric Banding and the Fine Art of Eating BT Online Editor | September 22, 2011 by Paul O’Brien, MD Dr. O’Brien is from the Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia. Bariatric Times. 2011;8(9):18–21 Funding: No funding was received for the preparation of this article. Financial Disclosure: Dr. Paul O’Brien is the Emeritus Director of the Centre for Obesity Research and Education (CORE) at Monash University, which receives a grant from Allergan for research support. The grant is not tied to any specified research projects and Allergan has no control of the protocol, analysis and reporting of any studies. CORE also receives a grant from Applied Medical toward educational programs. Dr. O’Brien has written a patient information book entitled The Lap-Band Solution: A Partnership for Weight Loss, which is given to patients without charge, but some are sold to surgeons and others for which he receives a royalty. Dr. O’Brien is employed as the National Medical Director for the American Institute of Gastric Banding, a multicenter facility, based in Dallas, Texas, that treats obesity predominantly by gastric banding. Abstract The author reviews the physiology of eating and what the adjustable gastric band does to the function of the distal esophagus and upper stomach of the patient. The author also provides the “Eight Golden Rules” on proper eating habits for patients of laparoscopic adjustable gastric banding, including what, when, and how they should eat, in order to achieve optimal weight loss results. Introduction Laparoscopic adjustable gastric banding (LAGB) has been shown to enable patients with obesity to achieve substantial, durable, and safe weight loss,[1,2] which can help reduce or resolve multiple diseases,[3] improve quality of life, and prolong survival in patients with obesity.[4] LAGB is a weight loss surgical procedure performed solely for the purpose of affecting a key physiological function in weight loss, appetite control. In 2005, we conducted a randomized, blinded, crossover trial that showed that the LAGB controls the appetite.[5] However, if the LAGB is not placed properly or if the patient does not eat properly, it will not perform at an optimal level. For example, if the band is placed too loosely, then it will not provide the proper level of reduced satiety and appetite, and likely will have little effect on the patient’s weight and health. If the band is placed too tightly or if patient eats too fast or takes large bites of food, slips and enlargements can occur, leading to reflux, heartburn, vomiting, and sometimes the need for revision. Optimally, the band should be adjusted so that it squeezes the stomach at just the right pressure. If the patient eats correctly and the band is placed correctly, the LAGB should adequately control the patient’s appetite, resulting in optimal weight loss. The Physiology of LAGB Dr. Paul Burton, a bariatric surgeon at the Centre for Obesity Research and Education, Melbourne Australia, has studied the physiology and the pathophysiology of the LAGB closely. He used high-resolution video manometry, isotope transit studies, endoscopy, and contrast imaging to understand what happens during eating in normal controls, eating in patients who are doing well after LAGB, and eating in patients who have symptoms of reflux, heartburn, and/or vomiting after LAGB.[7–15] In Burton’s series of articles, he concluded that in LAGB, it is not the band that fails, but rather the patients who receive the band and, more importantly, the doctors who care for them. Many years ago at the Centre for Obesity Research and Education (CORE), my colleagues and I developed the Green Zone chart, a conceptual way of identifying the optimal level of band restriction (Figure 1). When a patient is in the yellow zone, it is an indication that the band is too loose. When in the yellow zone, a patient may be eating too easily, feeling hungry, and not losing weight. When a patient is in the green zone, he or she does not feel hungry, is satisfied with small amounts of food, and is achieving weight loss or maintaining a satisfactory level of reduced weight. When a patient is in the the red zone, it is an indication that the band is too tight. The patient experiences reflux, heartburn, and vomiting. The range of food the patient in the red zone can eat after undergoing LAGB is limited and he or she may start to eat abnormally (so-called maladaptive eating), favoring softer, smoother foods like ice cream and chocolate. While in the red zone, patients will not lose weight as effectively and they may even gain weight. Burton measured the pressure within the upper stomach beneath the band in numerous patients when they were in the green zone. He found the optimal pressure was typically 25 to 30mmHg. The art of adjustment is to find the level of Fluid in the band that achieves that pressure range. That level of pressure generates a background sense of satiety that persists throughout the day. The patient, when correctly adjusted, normally will not feel hungry upon waking in the morning, and throughout the day should feel much less hungry than he or she did before band placement. In my experience, it is common for LAGB patients to have no feeling of hunger in the morning. Then, during the day, a modest level of hunger will develop, which a small meal should satisfy. One of the key lessons learned from Burton’s studies was that each bite of food should pass across the band completely before another bite is swallowed. There is no pouch or small stomach above the band and there should never be food sitting there waiting. The esophagus is a powerful muscular organ that typically generates pressures of 100 to 150mmHg, but it is capable of generating pressures above 200mmHg. Esophageal peristalsis squeezes the bite of food down toward the band and then progressively squeezes that bite across the band. Each bite must be squeezed across the band before the next bite starts to arrive. Figure 2 shows a bite in transit across the band. A single bite of food, chewed well until it is mush, will move down the esophagus by peristalsis. At the level of the band, the esophageal peristalsis will squeeze that bolus of food across the band. It takes multiple squeezes (usually 2–6 squeezes or peristaltic waves) to get that bite of food across in a patient with a well-adjusted band (Figure 2). Those squeezes generate a feeling of not being hungry and stimulate a message that passes to the hypothalamus to indicate that no more food is needed. If a single bite of food is able to generate between two and six waves of signal, a meal of 20 bites may generate 100 or more signals. This is enough to satisfy a person and is enough to signal him or her to stop eating. We recognize two terms for appetite control, satiety and satiation. Satiety refers to the background control of hunger that is present throughout the day regardless of eating. In the LAGB patient, satiety is generated by the band exerting a constant compression on the cardia. Satiation is the early control of hunger that comes with eating. In the LAGB patient, satiation is generated by the squeezing of the bolus of food across the band during a meal. Each squeeze adds to the satiation signal. There are sensors in the cardia of the stomach that detect this squeezing. The exact nature of these sensors is still to be confirmed but they must be either hormonal or neural. We know that satiety and satiation are not mediated by one of the hormones currently known to arise from the upper stomach.[16] Ghrelin is a hormone that stimulates appetite. A number of hormones that can be derived from the cardia of the stomach are known to reduce appetite. None of these hormones are found to be raised in the basal state after gastric banding and none can be shown to rise significantly after each meal.[16] Vagal afferents are plentiful in the cardia, and one group of afferents has a particular structure that lends itself to recognizing the compression of the gastric wall associated with squeezing of the bite of food across the band. In my opinion, the intraganglionic laminar endings, better known as IGLEs, are the most likely candidate as mediator of the background of satiety throughout the day and the early satiation after a meal. The IGLEs lie attached to the sheath of the myenteric ganglia and are known to detect tension within the wall of the stomach. They are low-threshold and slowly adapting sensors and therefore are optimal for detecting continued compression of cardia of the stomach over a 24-hour period. The several squeezes that go with the transit of each bite stimulate the IGLEs further. The signal passes to the arcuate nucleus of the hypothalamus and the drive to eat is reduced. The lower esophageal contractile segment. Burton developed the concept of the lower esophageal contractile segment (LECS). It is made up of four parts: the esophagus, the lower esophageal sphincter, the proximal stomach (including the 1cm or so above the band and the 2cm of stomach behind the band), and the band itself (Figure 3). As the esophagus squeezes the bolus of food down toward the band, the lower esophageal sphincter relaxes as this peristaltic wave approaches. It then generates an after-contraction, which can maintain some of the pressure of the peristaltic wave as a part of the food bolus is squeezed into that small segment of upper stomach. The upper stomach, including the area under the band, is sensitive to these pressures. It generates signals to the hypothalamus. These signals may be hormonal but are more likely to be neural. A correctly adjusted band will generate a basal intraluminal pressure of 25 to 30mmHg, providing a resistance to flow. The segment of the bolus that is squeezed through generates more signals from that area. Keeping the LECS intact is a key requirement for success with the gastric band. Bad eating habits (e.g., insufficient chewing, eating too quickly, taking bites that are too large) hurt the LECS. If those bad habits go on for long enough, stretching occurs and the power of peristalsis is lost, leading to the return of hunger (Figure 4).[11,12] The Fine Art of Eating A quality aftercare program is essential to successful weight loss in patients after LAGB. Before making the decision to proceed with LAGB in patients, I promise my patients three things: 1) to place the band in the optimal position safely and securely, 2) that they will have permanent access to a skilled aftercare program, and 3) that I will give them the information they need to obtain the best possible weight loss from the band. In return, I ask for three commitments from my patients: 1) that they follow the rules regarding eating after undergoing the procedure, 2) that they follow the rules regarding exercise and activity, and 3) that they always come back for follow up no matter how many years have passed.[6] The “Eight Golden Rules.” At my facility, we summarized guidelines for eating after LAGB into what we call the “Eight Golden Rules” (Table 1). These rules are included in a book and DVD given to every patient who undergoes LAGB at the facility.[6] The rules are also posted on www.lapbandaustralia.com.au and are reinforced at most aftercare visits. These eight golden rules must become part of each patient’s life. The effect of the LAGB procedure on hunger facilitates a patient’s adherence to the rules, making it more likely that he or she will follow them. However, achieving positive results with LAGB requires a working partnership between the physician and patient. Adhering to these rules is the patient’s part of the partnership, and he or she ultimately is responsible for the success or failure of weight loss following LAGB. What to eat. After undergoing LAGB, patients should eat small amounts of “good food,” meaning food that is protein rich, of high quality, and in solid form. Each meal should consist of 125mL or 125g (i.e., about half of a cup of food). This measure of “half a cup” is a concept rather than a real measure of food, as some foods, such as vegetables and fruit, are composed largely of Water and this has to be allowed for in some way. Thus, I allow exceeding the “half a cup” limit a little for vegetables and fruit. We instruct patients to put each meal on a small plate and to use a small fork or spoon. The patient should not expect to finish all of the food on the plate, but rather he or she should plan to stop when he or she is no longer hungry. Any food left on the plate should be discarded. Protein-rich foods. Protein is the most important macronutrient in the food a LAGB patient eats. At our clinic, we recommend that our patients consume approximately 50g of protein per day. We have measured protein intake of our patients (Table 2) and have monitored their blood levels. We have not seen any protein malnutrition after LAGB, indicating that a daily intake of about 50g a day is sufficient. Table 2 shows the energy and macronutrient intake of 129 consecutive patients measured before and at one year after LAGB. Note the mean energy intake is reduced by approximately 1500kcals.[17] The best source of protein is meat; however, red meats, such as beef and lamb, tend to be difficult to break up with chewing in order to be sufficiently turned into mush. It is much easier to break up fish with chewing, and many fish are high in protein, including shellfish. chicken, duck, quail, and other birds can also be cooked to be easily chewed to mush before being swallowed. eggs and dairy, including cheese and yogurt, are also excellent protein sources. For nonanimal sources of protein, a patient should consider lentils, chickpeas, and Beans. Half of the “half a cup” allotment per meal should comprise protein-rich food. The other half should be made up of vegetables and/or fruits. I recommend to my patients that they eat more vegetables than fruit because vegetables have less sugar. Any space left in the “half a cup” can be used for the starches, (e.g., bread, Pasta, rice, cereals, potatoes), though I recommend to my patients that they eat a minimal amount from this group of foods as they tend to provide no important nutritional benefit. High-quality foods. High-quality food are foods that are minimally processed, natural, and whole. We encourage our patients to look for quality over quantity—for example, they might try sashimi-grade tuna, smoked salmon, duck breast, lobster, or even a simple poached egg. It is also important to remind your patients that there is no limit to the amount of herbs and spices that can be used to enhance the flavors of their foods. Solid foods. The patient should choose solid foods over liquids whenever possible. Liquids pass too quickly across the palate and, more importantly, too quickly across the band. There is no need for the esophagus to squeeze liquid, and without the squeeze, there is no stimulation of the IGLEs and no induction of satiety; therefore, eating calorie-containing liquids may negatively impact a patient’s weight loss. When to eat. After undergoing LAGB, a patient should eat three or less times per day. If the patient is in the green zone, meaning that the band is adjusted correctly, there should be no need for him or her to eat between meals. In fact, even three meals a day may be more than needed for satiety. In my experience, patients have little interest in eating in the morning. By late morning or early afternoon, patients may start to notice some hunger, which indicates that it is time to have a first small meal. In the evening, patients may have another meal. Most importantly, patients should be instructed that a meal missed is not to be replaced later on. The typical human body is satisfied with a maximum of three meals per day but often is happy to accept two or even one meal per day. Patients should be reminded that there should be no snacking between meals. If a patient finds that he or she is hungry by late afternoon, encourage him or her to eat something small and of high quality, such as a piece of fruit or some vegetables, just to tide him or her over until the evening meal. The patient should then visit the clinic to check whether or not he or she is in the Green Zone. It is important that the patient adhere to the aftercare program to monitor whether or not he or she is in the green zone. If not in the green zone, the patient will need to have fluid in the band increased or decreased. How to eat. Take a small bite and chew well. The “half a cup” of food should be placed on a small plate. The patient should use a small fork or a small spoon to eat. A single bite of food should be chewed carefully for 20 seconds. This provides the opportunity to reduce that bite of food to mush. It also provides the important opportunity for the patient to actually enjoy the taste, the texture, and the flavor of the food. Encourage your patients to enjoy eating more than they ever have. After chewing the food until it is mush, the patient should swallow that bite. Swallow, then wait a minute. The patient must wait for that bite to go completely across the band before swallowing another bite. Normally, it will take between two and six peristaltic waves passing down the esophagus, which can take up to one minute. This is probably the biggest challenge of educating the patient who has undergone LAGB. You must instruct the patient to eat slowly—chew well, swallow, and then wait one minute. A meal should not go on for more than 20 minutes. At one bite per minute, that is just 20 small bites. The patient probably will not finish the “half a cup” of food in this time. In this case, the patient should throw away the rest of the food. After undergoing LAGB, the patient should always expect to throw away food and to never eat everything on the plate. If it takes between two and six squeezes to get a single bite of food across the band and each squeeze generates satiety signals, then 20 bites should be generating 40 to 120 signals. The actual number will depend on the consistency of the food, the tightness of the band, and the power of the esophagus. With good eating practices and optimal band adjustments, the patient should not be hungry after 20 bites or less. As soon as the patient is no longer hungry, he or she should stop eating. After undergoing LAGB, the patient should never expect to feel full. Feeling full means stasis of food above the band and distension of that important part of the LECS above the band. This destroys the LECS, the mechanism that enables optimal eating behavior and appetite control. A patient should always keep this process in mind. If the patient finds that after eating the “half a cup” of food he or she is still hungry, he or she should review his or her eating practices, correct the errors, and consider the need for further adjustment of the band. If this is occurring, it is usually an indication that the patient is not in the green zone. Eat a small amount of good food slowly. These eight words are the key to success. Small amount refers to small bites, the small fork (e.g., oyster fork), and a total meal size of half a cup. Good food refers to protein-rich, high-quality, and solid food. Slowly refers to chewing well, swallowing, and waiting a minute. Try to repeat these eight words to every patient every time you see them. Get them to repeat it at every meal. The failure of the gastric band can almost always be traced to failure of this process. Addressing the Challenges The two principal challenges after LAGB are weight loss failure and the need for revisional surgery due to proximal enlargements above the band. Weight loss failure will occur if the band is not placed or adjusted correctly or if the patient does not adhere to the guidelines of proper eating and exercise. When a patient is not achieving results after his or her LAGB operation, the doctor should check to ensure that the band is correctly and safely placed. The most common reason for weight loss failure is poor eating behavior, which leads to enlargement above the band. There are three common eating errors: 1. The patient is not chewing the food adequately. Food must be reduced to mush before swallowing. If it cannot be reduced to mush, it is better for the patient to spit it out (discreetly) than to swallow it. 2. The patient is eating too quickly. Each bite of food should be completely squeezed across the band before the second bite arrives. 3. The patient is taking bites that are too big to pass through the band. Each of these errors leads to a build up of food above the band where there is no existing space to accommodate it (Figure 4). Space is then created by enlargement of the small section of stomach or by enlargement of the distal esophagus, both of which can compromise the elegant structure of the LECS. If the LECS is stretched, it cannot squeeze. Without the squeezing, satiation is not induced. When satiation is not induced, hunger persists, more eating occurs, and stretching continues. If our patient continues this each day for a year, it is inevitable that chronic enlargement will occur, the physiological basis for satiety and satiation is harmed, and stasis, reflux, heartburn, and vomiting supervene. The doctor should continually review the Eight Golden Rules for proper eating and exercise with each patient. For optimal weight loss following LAGB, the patient should have access to a comprehensive long-term aftercare program for clinical support and optimal band adjustments and he or she must follow the guidelines regarding eating and exercising for the rest of his or her life. “Eat a small amount of good food slowly” is the key to optimizing the gastric band.

Sadly, I have not seen very good outcomes with repeated port infections. Some have to get the port removed, and get on heavy antibiotics for a while, sometimes 6 months or more to try to get rid of all infection, and in most cases does not work out long term. Also you did not mention if you were diabetic or not, but, on Allergan website, diabetics tend to have a hard time with the band, than others, since they are more prone to infections. Infection can spread up the tubing to the band and cause band migration (erosion), if I were you, I'd be looking into eventually removing the band, and possibly looking for alternatives for weight loss. I am wishing you the best.

Another thing, I want to say, NEVER let the scale -- control whether you need some saline removed. This is where many get into trouble, PBing is not painful for most, so many "get rid' of their food daily and don't think twice about it. Until the damage gets done and then REAL vomiting occurs, with awful bile reflux, frothing at the mouth, not being able to sleep without 'stuff' coming back up at night. These things can be prevented with not keeping the band dangerously too tight, taking the time to slowly chew your food, and not purging your food. It's just that simple, you don't have to abuse your band to lose weight, I don't know why so many women do it. She is a very pretty girl, I hope she can get some help, but she should know that it will be VERY HARD to keep her weight down WITHOUT a tool in the long run. This is why I use to warn newbies -- don't abuse your band and lose it, have the band to "help you" and not do all the work, and you can keep it for a long time. Also ButterFly: you are in GOOD hands, you have one of the most experienced lap band surgeons in the US.