Secondary Achalasia due to AGB (warning, complication post) :). The Why??

[Baba Wawa 543]

Please read this with an open mind. It might just save your band and damage later on.

I've been trying to figure this out, since my Dx was confirmed last week. I kept my band loose, 3.5 cc in 11 cc Realize C band. I ate per my doctor's and nutritionist's directions. I didn't drink with meals, though drinking with meals might be better. I cut my food into 1/4 inch pieces, chewed 15-25 times. In fact, I was doing all this for 3 months prior to surgery. I ate 1/2 to 1 cup food, taking 20-30 min to finish. I stopped eating with the "soft stop" signs. I've come across some information that might explain what happened to me and why. So what's the problem?

The problem is that our pouch can only hold 1-2 oz of food. A half cup is 4 oz. If you're a little bit too tight, food will be retained in the pouch, putting back pressure on the gastroesophageal junction. Eating a cup of food a year or more out, isn't unusual and this would be 4-8 times the capacity of the pouch. As we're told not to drink at all with our meals, the food stays in the pouch, longer, which can be a problem. Any random tightening, a fickle band, can have disastrous consequences to the esophageal function. An ounce is appx 29 cc, my manometry test involved just 45 cc of saline (about 1.5 oz). It doesnt take much to cause problems. The esophagus is not intended to hold food at all. Continued episodes of this causes nerve damage and will present initially as heartburn or GERD symptoms. This is misleading and potentially damaging. How many times have you seen a post where someone states their heartburn had returned and their doctor puts them back on a PPI? What is needed is an Esophogram to determine if they've become too tight (if its been some time since their last fill) or a small unfill if they've had a recent fill. If there is any chest or epigastric pain, further tests would be in order to rule out esophageal problems. Manometry can pick up small changes indicating damage that cannot be seen with EGD or UGI, avoiding further damage by unfilling the band or removing it all together.

This sort of explains why the "rules" around eating and drinking with a band might result in fewer complications and that quicker pouch emptying might be a good thing. I've been drinking with meals again for a few months, but have noticed no difference in satiety.

Let me emphasize something here. This post is intended to educate and share knowledge in order to spare someone else the problems so many of us have had. Most of the time achalasia secondary to AGB is reversible with emptying or removing the band, but it is a contraindication to VSG, eliminating that surgery as an option for revision. Getting a band might prevent a person from being able to revise to their surgery of choice, eliminating all but malabsorptive options (RNY and DS).

http://www.ajronline.org/doi/full/10.2214/AJR.04.0655

http://link.springer.com/article/10.1381%2F09608920677522200 5?LI=true

http://www.ncbi.nlm.nih.gov/pubmed/22411570

http://www.searchmedica.com/xml-resource.html?c=pc&ss=defLin k&p=Funnelback&rid=http%3A%2F%2Fubm-search01.squiz.co.uk%2Fs earch%2Fcache.cgi%3Fcollection%3Dpubmed%26doc%3D61%252F21683 804.xml%26off%3D0%26len%3D-1%26url%3Dhttp%253A%252F%252Fubm- search01.squiz.co.uk%252Fpublic%252Fpubmed%252F21683804.xml& t=pubmed

[2muchfun 8,927]

If our pouch is behaving as it should, shouldn't the food be pushed through the band in one minute? Would your situation be an example of a pouch that is not behaving normal?

I can see if the band is too tight that food may not go through in one minute, but for me, I can eat two bites and be stuck if I am too tight, eat too big or too fast. For me, the discomfort of having more than two bites in my pouch is very uncomfortable and it stops me from eating anything until the obstruction is cleared. Stuffing 1 cup or even 1/2 cup in my pouch would be incredibly painful and ultimately impossible.

Are you saying that your pouch did not give off any indication that it was full, such as a stuck episode?

I do recall maybe a year ago someone else reported a dilated pouch and esophogus and it puzzled me as to how that could happen since getting stuck is so uncomfortable for me that I can't imagine dilating my pouch or esophogus due to the pain involved?

I did notice that a small study indicated that this happens with patients with pre-existing conditions? "Patients with pre-existing LES insufficiency appear to be at risk for pouch dilatation and esophageal decompensation despite normal band position and normal stomal width"

Well, that sucks huh? Good luck. Are you going to have your band removed, unfilled or stay the course?

tmf

[balbuquerque 85]

I really appreciate your sharing your experience. I am 24 days post op with a very slow recovery, because of nerve damage ( I believe) I do not have any fill as of yet. I'm suppose to go in for one in two weeks , however I've been contemplating not doing so, just yet as I feel satisfied with a cup of good. Maybe I should reduce that. I really don't want to be too aggressive with fills if I don't need it. I've already lost twenty pounds and if I follow the rules and make good food choices I should continue to loose without adding more stress to my stomach. Again thanks for sharing.

[Baba Wawa 543]

If our pouch is behaving as it should, shouldn't the food be pushed through the band in one minute? Would your situation be an example of a pouch that is not behaving normal?

I can see if the band is too tight that food may not go through in one minute, but for me, I can eat two bites and be stuck if I am too tight, eat too big or too fast. For me, the discomfort of having more than two bites in my pouch is very uncomfortable and it stops me from eating anything until the obstruction is cleared. Stuffing 1 cup or even 1/2 cup in my pouch would be incredibly painful and ultimately impossible.

Are you saying that your pouch did not give off any indication that it was full, such as a stuck episode?

I do recall maybe a year ago someone else reported a dilated pouch and esophogus and it puzzled me as to how that could happen since getting stuck is so uncomfortable for me that I can't imagine dilating my pouch or esophogus due to the pain involved?

I did notice that a small study indicated that this happens with patients with pre-existing conditions? "Patients with pre-existing LES insufficiency appear to be at risk for pouch dilatation and esophageal decompensation despite normal band position and normal stomal width"

Well, that sucks huh? Good luck. Are you going to have your band removed, unfilled or stay the course?

tmf

If our band isn't too tight, food can get "packed" in there by eating too fast, for sure. For about 15 months I was fine, only stuck once when we were on vacation and I tried to eat tuna w/o mayo. :-/

What I'm speaking of is the reported "self-tightening" or "fickle" band. Yes, you might get a sign that it's time to stop, or maybe not. My band would seem to be fine, no unpleasant feeling, meal seemed to go down fine. A half hour later, boom, up it would come. It was as if someone squeezed a bulb syringe. I found out it was spasms.

My warning is really meant for those who start to have heartburn or reflux that had "resolved" with banding. It's a very early sign of damage to the LES and if dealt with ASAP, further damage can be avoided,

It's important to note that my situation deteriorated after a complete unfill. Prior to that, the band had actually tightened (15 months after my last fill) to the point that barium would only drip thru the stoma. I have a feeling that when I have the band removed, there will be a lot of scar tissue under the band.

[elcee 3,340]

I think a lot of the problem is due to the changing views on how the band works. When I was banded , almost 4 years ago, I was told and all the available information stated that the band was designed to allow the food to pass from the top part to the lower part of the stomach very slowly. That is should take at least 20 minutes but could take longer. In Australia we were never told to measure in cups but rather use a small plate as our guideline. We were told to eat slowly but never told that we had to wait a minute or more between bites.

Somehow over the last 4 years the thinking on how the band works has changed.I'm still not sure if the new thinking applies to all bands or if it is only the more recent surgeries that have had a different placement that it applies to. I know some people with 4cc bands that will swear blind that food does not pass through their pouch quickly.

I think that the misinformation has caused a lot of confusion and it may also have contributed to a lot of the problems.

Achalasia is a possible complication.About a year ago my Dr told me that it was something that they were seeing an increase of but they weren't sure why.

[Baba Wawa 543]

There is going to be a major rethinking of the concept of banding. In Germany, they're no longer doing bands and doing some extensive studies on those who have or have had bands to determine if its a viable option for WLS moving forward.

[JACKIEO85 308]

I really appreciate your sharing your experience. I am 24 days post op with a very slow recovery, because of nerve damage ( I believe) I do not have any fill as of yet. I'm suppose to go in for one in two weeks , however I've been contemplating not doing so, just yet as I feel satisfied with a cup of good. Maybe I should reduce that. I really don't want to be too aggressive with fills if I don't need it. I've already lost twenty pounds and if I follow the rules and make good food choices I should continue to loose without adding more stress to my stomach. Again thanks for sharing.

I think your WISE in waiting, I personally waited for 12 weeks before my first fill ,even when they said 6 weeks was the norm. I just started having reflux after my last 2 fills so I have been back to 5cc from original 9cc fill. I haven't gained, but have had "other issues" to contend with that are more important right now. good luck... balbuque

[Scorpio Girl 88]

This wasn't something I was warned about in my pre op evaluations. There were discussions about reflux, vomiting, etc, but always within the context of eating habits, things like chewing too little, eating too fast or too late. Being less than 3 years out, this is troubling to me. Thanks for the heads up!

[balbuquerque 85]

3dragonfly this is of a lot of concern because its all very misleading. Something as simple as going back to work was very misleading. I was told that I could go back to work the next day , if I had a desk job. Thank goodness that I didn't listen to that.

[Baba Wawa 543]

3dragonfly this is of a lot of concern because its all very misleading. Something as simple as going back to work was very misleading. I was told that I could go back to work the next day ' date=' if I had a desk job. Thank goodness that I didn't listen to that. [/quote']

They make getting a band (and a lot of other surgeries) sound like a trip to the dentist. I was exhausted for about 3 weeks post banding.

[balbuquerque 85]

It's unacceptable

[2muchfun 8,927]

I went to 3 different seminars and 4 different support groups prior to being banded. No one every insinuated I could go back to work in one day(and I've never heard of anyone being told 1 day till now?). I was told some can go back in 3-4 days and some may take a week to recover. It was always ambiguous just as it should have been.

And I highly doubt anyone was ever told getting a band was like going to a dentist. I guess I'll leave your little hyperbolic rants to yourselves but you're only kidding yourselves!

[☠carolinagirl☠ 18,721]

I went to 3 different seminars and 4 different support groups prior to being banded. No one every insinuated I could go back to work in one day(and I've never heard of anyone being told 1 day till now?). I was told some can go back in 3-4 days and some may take a week to recover. It was always ambiguous just as it should have been.

And I highly doubt anyone was ever told getting a band was like going to a dentist. I guess I'll leave your little hyperbolic rants to yourselves but you're only kidding yourselves!

i have had major surgery before and it was exhausting completely and not just pain wise.....surely a newbie who never had surgery could be suprised....but i have read numerous posts in my year here where after surgery, some are completely shocked that it hurts alittle bit...seems like the dr's are not doing their job and the patient really needs to realize its major surgery at least.

[balbuquerque 85]

I've had seven surgeries in my life, Two c-sections, hemorrhoidectomy, Carpel tunnel, shoulder surgery, fibroid embolization, and the lap band. By far the lap band has been the longest recovery. I like when people share their experiences, regardless of whether I can identified with them or not. It's about sharing, and being generous with your knowledge.

[Baba Wawa 543]

I went to 3 different seminars and 4 different support groups prior to being banded. No one every insinuated I could go back to work in one day(and I've never heard of anyone being told 1 day till now?). I was told some can go back in 3-4 days and some may take a week to recover. It was always ambiguous just as it should have been.

And I highly doubt anyone was ever told getting a band was like going to a dentist. I guess I'll leave your little hyperbolic rants to yourselves but you're only kidding yourselves!

I think you're assuming a lot. Many band clinics paint a very rosy picture of WLS and banding in particular. There are plenty of posts on forums of people going back to work in 1-3 days, as well. Hyperbole it's not. It's a reflection of our society's need for instant gratification.

I also think your reference to rants is a bit sexist. Just my $.02

...and it took a whole 30 seconds to find a recent post referring to this. http://www.lapbandtalk.com/topic/168484-how-long-should-i-take-off-work/