Swedish Adjustable Gastric Band (SAGB)

The Swedish Adjustable Gastric Band (SAGB) was developed in Sweden in 1985 and has been available globally since 1996. A low-pressure soft band is placed around the upper most part of the stomach. The gastric band forms the stomach into two sections, with a small opening between the sections allowing food to pass through. As this section of the stomach fills and stretches, nerves in the stomach wall send signals to the satiety centre of the brain causing you to feel satisfied for up to several hours.

The SAGB will assist you to avoid over-eating and to decrease your overall daily food (calorie) intake. As your eating patterns change and you become accustomed to eating less, you can achieve sustainable weight loss, which in turn can lead to a healthier lifestyle with reduced risk of obesity-related health problems.

Although the SAGB is a tool for helping you to induce sustainable weight loss it is not a self acting slimming device. Your postoperative dietary and behavioural compliance, including exercise, is essential for successful weight loss as well as avoiding complications.

Advantages of the SAGB

• restricts the amount of food that can be consumed at a meal
• food consumed passes through the digestive tract in the usual order allowing it to be fully absorbed into the body
• can be placed using keyhole (laparoscopic) surgery
• can be adjusted to increase or decrease restriction
• surgery can be reversed

The SAGB operation

The procedure is normally performed by using keyhole (laparoscopic) surgery, which is a minimally invasive surgical technique where instruments allow access to the stomach through small 1-2 cm holes in the abdomen compared to a single large incision 15 cm or more in length. The surgeon views the inside of the abdomen on a TV while performing the operation. The potential advantages of laparoscopic surgery are that it may result in a quicker recovery and less pain than traditional open surgery.

Click to view an interactive animation of the procedure.

Band adjustments after surgery

During the operation a titanium fluid port will be attached to firm tissue structures of the abdominal wall and will sit permanently under the skin. The port is attached to the band via a thin catheter and allows your doctor to add or subtract fluid from the band according to your individual requirements.

The SAGB is empty when first placed around the stomach and after about 4 weeks the band will have healed into place sufficiently for the system to have its first fluid adjustment.

The doctor will use a special "Huber" type needle to insert fluid into the port. A typical fluid adjustment can be done in the doctor's office or in a radiology department if the doctor wants to view the fluid entering the band using a special X-ray.

The amount of fluid placed in the band as well as the frequency of fills is determined by your doctor according to your weight loss requirements.

Banding Complications and Risks

Infection and migration

An infection may develop either in the port area or in the abdomen, and in some instances this may cause the band to migrate into the stomach. In such a case, reoperation normally is necessary. Most of the complications linked to migrations have occurred as a result of too much fluid being injected into the SAGB. The balloon must therefore be filled with no more than 9 ml of fluid, as recommended by the manufacturer. In nearly all of the reported cases of migration the balloon had a fluid content above 11ml. This is 2ml more than the recommended maximum volume. The rate of migration will be kept low by avoiding overfilling of the system. Migration can also be caused by a subclinical infection. Even if this is very rare, it is important that you do not let anyone inject liquid into your port without previously applying a swab soaked in 5% chlorhexidine spirit onto the skin for approximately ten minutes before the injection. Omitting skin preparation may result in an infection.

Leakage

Leakage from the SAGB or from the connecting tube between the balloon and the port may require reoperation. The balloon is made of fragile material, and leakage can occur either shortly after surgery or many years later. In the event of leakage, the SAGB can normally be easily replaced with a new one. Nowadays this is a rare complication, but you must be aware that there is a possible risk that in the long term the band may need to be replaced with a new one.

Slippage of the band and pouch dilatation

• The band may slip, and the pouch (the part of the stomach above the band) may become too enlarged, and a reoperation may be necessary.
• Punctures in the silicone band and port dislocation
• The injection port may dislocate.
• When injecting into the port, there is always the risk of puncturing the silicone tube.

However, should either of the above occur, both can easily be corrected with a small operation under local anaesthesia.

Other complications

Other complications have occurred. You should ask your doctor for more detailed information.

The risk of reoperation will always exist, even if none of the above-mentioned complications occur. You must understand that the possibility of reoperation is an integral part of the overall management of morbid obesity. Reoperations are considered a technical measure that is sometimes necessary.

As with any surgical procedure using general anaesthesia, there is, of course, a risk of complications with even the possibility of death. Please ask your doctor for more detailed information.

General Advice and Possible Minor Side-effects

Vomiting

Patients may vomit or feel pain after food intake. This can be caused either by a poor eating behaviour, or by the narrowing of the SAGB following the injection of fluid into the balloon. By eating slowly and calmly, you will learn to listen to the signals from your stomach. Regular vomiting is definitely a warning sign. In such cases, the amount of liquid in your SAGB may need to be readjusted.

Vitamins

During the phase of rapid weight reduction, vitamin supplements are advisable. A liquid vitamin mixture containing multivitamins, in particular the vitamin B complex, is recommended for at least the first 6 months following surgery.

Pregnancy

The period between surgery and weight stabilisation is considered to be a period of starvation. It is not advisable to become pregnant during starvation, despite the fact that the foetus has priority over the mother with regard to food. Should you nevertheless get pregnant, it is advisable to remove all the fluid from the balloon. You should wait until your weight has stabilised before becoming pregnant.

Medication

Tablets must be broken down into small pieces or crushed before they are taken. Patients should consult thier doctor about this matter.

Constipation

Many patients feel constipated after surgery. This is mainly because the reduced food intake leads to less faeces and thus fewer bowel movements. If laxatives become necessary, it is advisable to abstain from so-called bulking agents and instead use liquid laxatives, such as lactulose.

Doctor appointments

After surgery you must undergo regular check-ups as an outpatient. Generally, these check-ups will be carried out monthly, but soon visits should become less frequent. The SAGB will gradually be filled via the injection port during the first 18 months following surgery. During this period, your weight loss and level of well-being will be monitored. Once your weight has stabilised, check-ups will be necessary only when problems occur or on an annual basis.

Physical activity

It will be important to alter not only your eating habits, but also your level of physical activity. Patients are generally recommended to start exercising slowly. As weight loss is achieved, physical activities will gradually become easier.

 

Vertical Banded Gastroplasty

Vertical Banded Gastroplasty (VBG) is a purely restrictive procedure. In this procedure the upper stomach near the oesophagus is stapled vertically for about 6cm to create a smaller stomach pouch. The outlet from the pouch is restricted by a band or ring that slows the emptying of the food and thus creates the feeling of fullness.

Click to view an interactive animation of the VBG procedure.

Advantages

The primary advantage of this restrictive procedure is that a reduced amount of well-chewed food enters and passes through the digestive tract in the usual order. That allows the nutrients and vitamins (as well as the calories) to be fully absorbed into the body.

After 5 years, studies show that patients can maintain 50% of targeted excess weight loss.(1)

Risks

Postoperatively, stapling of the stomach carries with it the risk of staple-line disruption that can result in leakage and/or serious infection. This may require prolonged hospitalization with antibiotic treatment and/or additional operations.

Staple-line disruption may also, in the long-term, lead to weight gain. For these reasons, some surgeons divide the staple-line wall of the pouch from the rest of the stomach to reduce the risk of long-term staple-line disruption.

The band or ring applied may lead to complications of obstruction or perforation, requiring surgical intervention.