In my professional opinion this is only really necessary when (i) the surgery involves going into the abdominal cavity (i.e. certain general, gynaecological or kidney operations), or (ii) draining your stomach acid and bile (when your gut is expected to be slow to recover its normal function after being handled by the surgeon), or nasogastric tube feeding, is expected to be necessary.

Any bandster faced with the prospect of an significant unfill is going to be unhappy as obtaining good restriction again afterwards can be tricky and may require more than one fill (which may require payment in the private sector). Most patients find that upon band refilling after a defill (e.g. necessitated by either excessive restriction or gastritis) their “sweet spot” is not at the same filling volume as before. More significantly, the hospital they are booked into for the operation in question may not be able to offer the expertise and equipment (non-coring Huber needles) required for port access if they do not have either a bariatric surgery or an implanted pain pump programme! Do not allow anyone unfamiliar with port access and/or not in possession of Huber needles to “have a go” at unfilling your band, as the procedure is likely to be difficult, and any regular needle may damage the port membrane and cause a leak!

As you probably know, the field of weight loss surgery is dominated by the operating surgeons, and although anaesthetists are now beginning to develop subspecialisation in the area of bariatrics and obesity, we are as yet few in number and do not have as much patient contact as the surgeons; consequently we are not yet being heard as much as perhaps would be ideal – but then I would say that, wouldn’t I?!

There is genuine concern about acid reflux under anaesthesia, as this can cause serious problems if it gets inhaled into the lungs. In patients prone to gastro-oesophageal reflux disease (GORD), anaesthetists often choose to use an endotracheal tube (ETT), a more invasive airway, as this protects (isolates) the airway better from the upper intestine (gullet/stomach) than the less invasive LMA (laryngeal mask airway). Also, for patients with a heavy chest wall, the ETT allows higher ventilator inflation pressures to be applied than the LMA. However, there is a halfway house available, called a ProSeal LMA, which has a drainage channel specifically for passing a nasogastric tube into the stomach or allowing reflux to occur harmlessly. Bandsters with good restriction should theoretically be well protected from acid reflux once being fasted before surgery.

So, on the whole I don’t agree that a band defill should be necessary if you are only facing a “10 minute” ENT operation. However, if your anaesthetist (or surgeon) is unhappy with this opinion, they would have the ultimate say – but it would also fall to them to organise an unfill for you as part of your overall care. So, discuss it with them in as much detail as you and they feel is warranted! 

Interestingly, this point (the perioperative care of previously banded patients who may or may not fulfil the obesity criteria) is roundly ignored in the Association of Anaesthetists of Great Britain & Ireland’s (AAGBI) official guidance on PERI-OPERATIVE MANAGEMENT OF THE MORBIDLY OBESE PATIENT dated April 2007. I have written to the Society of Obesity & Bariatric Anaesthetists (SOBA), of which I am a member, to see if we can generate some consensus. Also, I know that work is going on behind the scenes involving the Royal College of Surgeons in England and three of its specialist societies most closely involved with bariatric surgery to organise a consensus conference on many issues surrounding WLS sometime next year. So watch this space – I really believe there will be more and better advice available in the not too distant future.

Kai Rabenstein

(We are grateful to Kai for providing this opinion and reinforce his view that any concerns should be discussed with your surgeon and anaesthetist)