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Why you may want to consider gastric sleeve surgery instead of the Lap-Band — or even have your Lap-Band removed.
Lap-Band surgery, or gastric banding, has been one of the most popular forms of weight-loss surgery since it was introduced in 2001. In recent years, however, popularity of gastric banding procedures has been sharply declining.
As more information has emerged from long-term studies, gastric banding has been revealed to be associated with serious complications that make it inferior to procedures such as gastric sleeve. Many people who have had Lap-Bands placed in the past are now choosing to have them removed.
What does the new data show about Lap-Band surgery, and is it still recommended for weight loss? If you already have a Lap-Band, should you consider having it removed?
History of the Lap-Band
The Lap-Band was approved by the FDA for weight-loss surgery in 2001. Much of the appeal of the Lap-Band stemmed from 2 key features: it’s adjustable, and unlike other forms of bariatric surgery, it’s reversible.
Gastric banding is also considered a minimally invasive procedure that can be performed laparoscopically. Unlike gastric bypass or gastric sleeve, it doesn’t involve cutting into the stomach or rerouting the intestines.
The ease of the procedure and claims of relative safety drew many people to gastric banding.
It appeared to be a simple solution to the often frustrating process of weight loss.
As recently as 2011, the number of Lap-Band surgeries performed was on par with gastric bypass. But recent, longer-term research has revealed that gastric banding can lead to significant complications, and that other forms of weight-loss surgery lead to better success rates and fewer complications.
The Lap-Band’s popularity has been in steady decline since 2011, and in 2018 it accounted for only 1% of weight-loss surgeries.
Gastric sleeve surgery is now the most popular, accounting for close to 61% of surgeries, while gastric bypass — the “gold standard” of weight-loss surgery — accounts for roughly 17%.
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In this study of 25 042 Medicare beneficiaries who had the gastric band placed between 2006 and 2013, 4636 patients (18.5%) underwent 17 539 reoperations (an average of 3.8 procedures/patient). During the study period, Medicare paid $470 million for laparoscopic gastric band–associated procedures, of which $224 million (47.6%) of the payments were for reoperations.
Jyothi R. Thumma, MPH – Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
How weight-loss surgeries work
There are 3 primary categories of weight-loss surgery:
- Restrictive procedures, which restrict how much food you can eat
- Malabsorptive procedures, which change the way your body absorbs calories
- Combination procedures, which have elements of both
How the Lap-Band works
Gastric banding is a restrictive procedure. The Lap-Band involves inserting a silicone band around the upper portion of the stomach to help create a feeling of fullness. The band can be “filled” or “unfilled” to help control the amount of restriction it delivers. Saline is inserted or removed through a port on the side of the abdomen to adjust the fit of the band.
How gastric sleeve works
Sleeve gastrectomy, or gastric sleeve, is also a restrictive procedure. With gastric sleeve surgery, roughly 75 percent of the stomach is removed, creating a narrow sleeve roughly the size and shape of a banana. This smaller stomach limits the amount of food that can be eaten, so patients eat less and consume fewer calories. Gastric sleeve also helps reduce food cravings and hunger, as the surgeon removes the portion of the stomach that produces ghrelin — a hormone that stimulates appetite.
How gastric bypass works
Gastric bypass is both restrictive and malabsorptive. The purpose of gastric bypass surgery is twofold: reduce the amount of food the patient can eat, and reduce the amount of fat and calories the body absorbs from food.
In a gastric bypass surgery, the stomach size is reduced, and the small intestine is rerouted to bypass the lower section of the stomach and a portion of the small intestine, effectively reducing calorie absorption.
Other forms of bariatric surgery include biliopancreatic diversion and gastric balloon surgery.
The darker side of the Lap-Band
All forms of weight-loss surgery pose certain risks, but the presence of the band around the upper portion of the stomach can lead to certain risks and complications that are unique to gastric banding.
Potential side effects of the Lap-Band include:
- Abdominal pain or pain when eating
- Band slippage, which occurs when the band slips out of the correct place. Band slippage can lead to complications such as vomiting, gastric perforation, and acid reflux.
- Infection at the port or band site, which may require removal of the device.
- Band intolerance, which can lead to excessive scar tissue formation, as well as nausea, vomiting, and reflux.
- Band erosion, which occurs when the band erodes through the outer stomach wall.
Lap-Band patients may also require heartburn medication, which can have an effect on bone density, and they may be at risk of long-term effects of malnutrition caused by a limited diet.
Lap-Band and disordered eating
The makers of the Lap-Band, Allergan, claim that it encourages healthier eating habits, but does it?
Perhaps not surprisingly, the Lap-Band can contribute to disordered eating. To relieve the pressure caused by the band, some Lap-Band patients deliberately vomit after eating. Many others will continue to primarily eat high-glycemic foods such as crackers and bowls of cereal, because fiber-rich foods like raw vegetables or greens are painful to digest.
Some people will purposely keep the band overfilled to make it harder to eat, despite the pain it causes. In these cases, rather than promoting healthier habits, the device becomes a crutch that will quit working if it ever needs to be removed.
The Lap-Band and hunger
Another drawback of the Lap-Band is that it does not produce any physiological or hormonal changes that help reduce hunger. Patients still feel the same level of hunger as before, but are unable to eat as much.
People often find ways to compensate, such as drinking more calories. Lap-Band patients often learn which high-calorie foods can easily slip through the narrow stomach opening. They may respond to hunger and cravings with foods such as milk shakes and mashed potatoes, ultimately impeding their weight-loss efforts.
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A large proportion of patients who had a gastric band placed underwent a reoperation. With an average of a 4.5-year follow up, 4636 patients (18.5%) underwent 17 539 reoperations (an average of 3.8 procedures per patient in addition to their index operation).
Andrew M. Ibrahim – MD, MSc, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
In a 2017 study that demonstrates just how problematic gastric banding can be, researchers looked at 16 years of data from 25,000 patients to determine how common additional surgeries were after the initial Lap-Band operation. They found that 20% of the Lap-Band patients required an additional operation.
That’s far higher than re-operation rates for gastric bypass and gastric sleeve, which fall between 3 and 9 percent. Many patients had more than one follow-up surgery. In fact, the average number of surgeries per patient was 3.8.
Inferior weight loss compared to other surgeries
Long-term success rates with the Lap-Band are also inferior to other forms of weight-loss surgery. A 2016 study found that Lap-Band patients lost significantly less weight than those who underwent gastric sleeve or gastric bypass.
Revisional surgery is common after Lap-Band
Emerging studies have shown that a number of Lap-Band patients have required additional surgeries after having their band inserted.
These additional surgeries may involve removing the band, replacing it, correcting band erosion, or a revisional surgery, which involves following the initial procedures with another type of weight-loss surgery, such as gastric bypass.
After 4 years, gastric bypass patients had lost 27 percent of their original body weight and gastric sleeve patients lost 17 percent. But Lap-Band patients lost only 10 percent.
Those numbers make it hard to justify the risks involved with gastric banding, and explain why many doctors no longer recommend gastric banding to their patients. Fewer patients are asking for the device, and fewer doctors are recommending it.
Be aware of the risks!
If you’re considering Lap-Band surgery, it’s important to do your research and be aware of the potential risks and complications.
Also be aware that having the band removed could come with a hefty price tag that insurance may not cover unless it’s medically necessary.
Talk to a bariatric surgeon to determine the best approach for your unique situation. A bariatric surgeon will be able to provide you with options for safe, evidence-based weight-loss procedures designed to help you reach and maintain your goal weight.
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Previous studies evaluating the rate of reoperation after a gastric band placement have been inconsistent. Initial trials that informed the FDA approval of the device reported reoperation rates as low as 4% with a 1- to 2-year follow-up.1,4 Subsequent similarly sized trials with longer follow-ups began reporting reoperation rates as high as 60%.7 The largest, long-term population-level estimates of the gastric band come from France, where a 7-year follow-up in a closed health care system detected a reoperation rate of 20%.31 To our knowledge, this study provides the first longitudinal, national population-based estimate in the United States and confirms the high reoperation rates seen elsewhere. Moreover, the finding of a 2.9-fold geographic variation may partially help explain the wide range of rates individually reported in previous smaller studies.
Justin B. Dimick, MD, MPH – Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor |
Surgical Innovation Editor, JAMA Surgery
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