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Lap-Band

Adjustable gastric banding is a form of weight loss surgery (bariatrics) designed for obesity patients with a body mass index (BMI) of 40 or greater. It employs an inflatable silicone band which is implanted around the top portion of a person’s stomach via laparoscopic surgery. The implanted device creates a small pouch at the top of the stomach which fills up quickly and restricts the movement of the food into the bottom part of the stomach. This restriction creates a feeling of fullness which helps the person to eat less and therefore lose weight. The band is adjustable via a subcutaneous access port. A saline solution can be injected into the band via this port to help to increase the feeling of restriction to a point known as the “sweet spot” where optimal weight loss can be reached. The ability to adjust the restriction makes this a good choice for women who wish to become pregnant after losing weight. The band can be unfilled to allow for more food to be eaten as necessary for a healthy pregnancy. The banding procedure, unlike traditional gastric surgeries like Roux-en-Y gastric bypass surgery (RNY), does not cut into or remove any part of the digestive system. The procedure can be reversed simply by removing the band, which can be done laparoscopically. With the band there are also no malabsorption or dumping issues since no intestines are removed or re-routed. All nutrients are digested normally, so the rate of weight loss is somewhat slower than RNY. On average, a “bandster” loses 1-2 pounds per week in the first year. This number can vary widely depending on a person’s motivation and restriction levels. Disadvantages of the procedure include that the patient is less likely to maintain weight loss over the long term when compared to someone who has undergone Roux-en-Y gastric bypass surgery or biliopancreatic diversion surgery. A common risk of gastric banding include vomiting, which occurs when the patient eats too much or the narrow passage into the larger part of the stomach is blocked. Another is slippage or wearing away of the band.

History of the procedure and device

The first gastric band was patented in 1985 by Obtech Medical of Sweden and is known as the Swedish Adjustable Gastric Band (SAGB). An American company, INAMED Health, later designed the BioEnterics® LAP-BAND® Adjustable Gastric Banding System. Their LAP-BAND System was introduced in Europe in 1993 and quickly became more popular than the SAGB. The LAP-BAND System received FDA approval for use in the United States in June 2001.

Indications

In general, gastric banding is indicated for people for whom all of the following apply:

  • Body Mass Index above 40, or those who are 100 pounds (45 kg). or more over their estimated ideal weight according to the 1983 Metropolitan Life Insurance Tables or those between 30 to 40 with co-morbidities which may improve with weight loss (high blood pressure, diabetes, sleep apnea, and arthritis).
  • Age between 18 and 55 years (although there are doctors who will work outside these ages).
  • Failure of dietary or weight-loss drug therapy for more than one year
  • History of obesity (generally 5 years or more).
  • Comprehension of the risks and benefits of the procedure and willingness to comply with the substantial lifelong dietary restrictions required for long term success. Acceptable operative risk.

It is usually contraindicated for people with any of the following: If the obesity surgery or obesity treatment represents an unreasonable risk to the patient. Glandular diseases such as hypothyroidism. Inflammatory diseases of the gastrointestinal tract such as ulcers, esophagitis or Crohn’s disease. Severe cardiopulmonary diseases or other conditions which may make them poor surgical candidates in general. An allergic reaction to materials contained in the band or who have exhibited a pain intolerance to implanted devices. Dependency on alcohol or drugs. Mentally retarded or emotionally unstable people.

Gastric banding as an alternative to other weight loss surgeries

  • Lower mortality rate, only 1 in 2000 versus 1 in 200 for Roux-en-Y gastric bypass surgery
  • Fully reversible, stomach returns to normal if the band is removed
  • No cutting or stapling of the stomach
  • Short hospital stay
  • Quick recovery
  • Adjustable without additional surgery
  • No malabsorption issues (because no intestines are bypassed)
  • Fewer life threatening complications (see complications table for details)

Losing weight after surgery

Proper adjustment of the band is very important to weight loss and the long term success of the procedure. Adjustments (also called "fills") are often done under fluoroscope so that the doctor is able to see the placement of the band, the port and the tubing which runs between the port and the band. The patient is put under the fluoroscope where he or she is given a small cup of a liquid containing barium. When swallowed, the drink shows up under the fluoroscope and can be seen moving past the restriction caused by the band. This allows the doctor to see the level of restriction in the band and to access if there are any problems - such as an enlarged pouch, prolapsed stomach (when part of the stomach moves into the band where it does not belong) or reflux caused by too much restriction. If any of these problems is discovered the doctor will likely remove all the saline from the band and have the patient return in a few weeks for reevaluation. Most of the time that is enough, but in a very small number of cases another surgery could be required.

Some more experienced doctors do their fills without the fluoroscope; e.g. this is standard practice in the main bariatric surgery clinic in Melbourne, Australia, where AGB placement has been performed for more than ten years. In these cases, patients visiting for a regular fill adjustment will typically find they will spend more time talking about the adjustment and their progress than the actual fill itself, which generally will only take about 60 seconds to two minutes.

For some patients this type of fill is not possible, for example due to partial rotation of the port, or excess tissue above the port making it difficult to determine its precise location, in which case a fluoroscope will generally be used.

On average, it takes three to five fills (where saline is inserted into the band via the subcutaneous port) for a person to reach the optimal restriction for weight loss. The amount of saline needed in the band varies from patient to patent. Some small number of people find they do not need a fill at all and have sufficient restriction right from the start, others may need all the way up the maximum their band will hold. The bands come in several sizes which can hold anywhere from 4 cm³ to 10 cm³ of saline. The size of the band used is determined by the surgeon during surgery based on the size and thickness of the patient's stomach.

The band is not filled at surgery because the stomach tends to swell after the surgery and filling it could cause total restriction, which is undesirable.

The patient is usually put on a liquid diet, followed by mushy foods and then solids. They may find that before their first fill that they are still able to eat fairly large portions. This is not surprising since before the fill there is little or no restriction and is why a proper post-op diet and a good after-care plan is critical to success. Most doctors make the first adjustment at four to six weeks out from surgery in order to give the stomach time to heal. After that fills are performed as needed. Some doctors are more aggressive than others, but most appear to require a 2-4 week wait between fills. It is very important to discuss post-surgical care and diet plans with your doctor if you are considering this surgery. Recommendations can vary dramatically from doctor to doctor and it is important to find a doctor with a good post-surgical plan. Some doctors maintain support groups, but unfortunately many of them mix RNY patients with gastric banding patients. Some gastric band recipients have criticized this approach because while many of the underlying issues related to obesity are the same, the needs and challenges of the two groups are very different, as are their early rates of weight loss. Some gastric band recipients feel the procedure is a failure when they see that RNY patients generally lose weight faster.

The average gastric banding patient loses 500 grams to a kilogram (1-2 pounds) per week consistently, but heavier patients often lose faster in the beginning. This comes to roughly 50 to 100 pounds the first year for most band patients. It is important to keep in mind that while they drop the weight faster in the beginning, most of the RNY patients will have the same percentage of weigh lost and comparable abilities to keep it off after only a couple of years. Gastric banding patients may have to work a little harder in the first couple of years, but the procedure tends to encourage better eating habits which help in producing long term weight stability.

Post-surgical diets

Gastric banding is intended to make it easier to lose weight. However, success with this procedure depends in large part on the diet and activities of its recipients. The post-surgical diet varies greatly depending on a person's surgeon, nutritionist, and personal philosophy. To generalize, the common wisdom about the post-surgical diet is one high in protein and low in carbohydrates - not dissimilar to an Atkins diet plan or many other currently popular high protein diets. The average diet contains 40 to 80 grams of protein and roughly 1200 to 1500 calories (5,000 to 6,300 kJ) per day. Banders are encouraged to eat protein first, then fruits and vegetables and only then starchy foods.

Someone who has had gastric banding for some time can eat anywhere from 1/2 to 1 1/2 cups of food per meal. This amount can vary depending on the softness of the food and the restriction of the person's band. Many people find that they are more restricted in the morning and that they loosen up over the course of the day. Women tend to have fluctuations in their restriction levels during their monthly cycle - often feeling particularly restricted when they are menstruating.

Immediately following surgery most patients are put on a liquid diet, although the details can vary widely from doctor to doctor. Generally, there are a couple of days of thin or clear liquids, followed by two to four weeks of soft or puréed foods, and then slowly the diet works up toward more solid foods.

When a patient reaches the point of optimal restriction, they often have a few foods that they find it best to avoid. Some people are unable to eat fluffy bread, rice, or pasta. Others have problems with oranges (because of the skin on the sections), grapes and other fruits with skins. Still others may find that they are unable to eat particular varieties of meat. In general, patients are advised to start slow, chew thoroughly, and see how they respond. There are no set rules for what you can and cannot eat that fit everyone. Most vomiting incidents with the newly banded happens due to insufficient chewing, eating too big of a bite at once, or eating a couple bites too many. As patients begin to understand the signals their body is sending them for when to stop eating, they vomit a good deal less.

The LAP-BAND in Australia

According to an August 2005 article in The Medical Journal of Australia , over 90% of weight loss surgeries in Australia are installations of the laparoscopic adjustable gastric band. Some of the more interesting findings in the study are these:

  • Our group has treated more than 2700 severely obese patients with the LAGB procedure since 1994 without a single perioperative death. In contrast, mortality from RYGB is reported at between 0 and 5%, with the ASERNIP-S systematic review showing a mean short-term mortality rate of 0.5% — ten times the risk of LAGB. [...]
  • All bariatric procedures have been able to achieve loss of more than 50% of excess weight. The ASERNIP-S systematic review showed greater weight loss after RYGB than LAGB during the first 2 years after the procedure, but the difference in weight loss was not significant at 3 and 4 years. In a recent review, we extended the data of the ASERNIP-S review by including all studies that included at least 50 patients, reported up to March 2004. This showed a substantial weight loss after both procedures, with an initial greater weight loss after RYGB but similar effectiveness for both procedures at 4, 5 and 6 years.

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