Most Saturday mornings my wife and I meet WLS patients with adjustable gastric bands (AGBs) who need their restriction adjusted. What we offer is advice and support as much as the actual volume adjustments. This sounds simple, but isn't.
How did we get into it? My wife had an AGB implanted in Belgium 3 years ago. During a follow-up visit to her surgeon, he expressed his surprise that there were so few fill providers in the UK, and gave me some basic training and several Huber needles. For an anaesthetist and critical care doctor, accessing a subcutaneous port was not daunting in any way. My services were first provided free of charge to fellow WLS members desperately needing an emergency defill. This experience clearly illustrated the unmet need for independent clinics offering easy access to an affordable fill adjustment.
However, optimal adjustment of a mechanical device alone is no guarantee of WLS success - in fact, over time we have come to realise that band restriction effects can be highly temperamental and somewhat unpredictable. The expected degree of restriction cannot always be accurately gauged by tracking filling volume or pressure, and bands can suddenly change their restriction without any change in internal volume. Clearly the factors affecting restriction are not as well understood as we would wish! Once proper restriction sets in (generally with a filling volume upwards of 5 millilitres), patients must identify eating patterns and foods which suit them and allow for weight loss at a healthy rate - these will differ between individuals. On rare occasions, patients may wish to take a "holiday" from their restriction to be able to properly celebrate an important event, and many (but not all) clinics will facilitate this by offering a temporary defill.
However, the path to a healthy weight is rarely smooth. Unless filled (in a stepwise manner) to adequate restriction in a timely fashion following their surgery, AGB patients are unlikely to lose much weight initially and can become thoroughly discouraged with the process. As the best top-up filling volume for fills at any point in time is a matter of educated guesswork, overfill and resulting excessive restriction are not uncommon; this may resolve within a few days, but can become a medical emergency if it doesn't. Unfortunately, district general hospitals are not usually geared to deal with the consequences. The majority of AGB implants take place outside the NHS, so financial considerations are also a factor in the mix, and we feel that some patients hesitate to have the necessary fine-tuning of their bands due to the fill fees charged by some private providers, or because they are afraid to venture beyond their original surgeon's services.
Occasional mishaps can occur, such as the "flipped" port which may become difficult or impossible to access. Undeniably, some patients find that their overwhelming need to eat leads them to discover ways and means to defeat their surgical restriction. In fact, most patients suffer minor setbacks of some kind or other; advice and support from experienced practitioners and fellow patients who "have been there" is therefore invaluable - but often hard to obtain. This is where websites such as WLSInfo can make all the difference. Peer-to-peer communication, be it through social networks, blogs or conventional media, is often the best source of quality information about good providers, solutions to problems, pricing levels, etc.
As a full-time NHS employee, I can only devote a small amount of my time to running the AGB clinic (www.fillprovider.net). At present, our income from the clinic does not yet cover the increase in my professional indemnity insurance fees. Our clinic's scope for capacity expansion is limited. But we like to think we offer a high-quality and affordable service to AGB patients, and would hope that clinics like ours will proliferate in the next few years.
Kai Rabenstein
