The Gastric Band
What is it?
Gastric banding is one of the newest options for surgical weight loss. Now that the five year results for the gastric banding have been reported, I can present this option to my patients with a realistic discussion of what to expect in the very near future, should they opt to undergo band placement. Armed with this information, my patients can make an informed decision and have with them my wholehearted support.
The data shows us that the banding is indeed a simpler operation than the gastric bypass, with less serious peri-operative (meaning right around the time of surgery) complications. (You can read about long-term complications below.) The weight loss at the end of the first year has been reported to be markedly lower than for the bypass (30 – 40 % of excess body weight lost for the band patients vs 50 – 75% with the bypass). For anyone who is considering the gastric banding, it is important to recognize that the weight loss is much slower, occurring over a period of 2 and occasionally 3 years. The weight loss has been shown in some studies to reach 60% by the two year mark and may continue to improve into the third year. Since the initial trials with the band, which revealed poor success rates relative to the bypass, there have been marked improvements in the design of the band and in post-operative management, which has anecdotally improved patient success. However, patients need to be aware that because of the relative “new-ness” of the band, no one can honestly predict what is likely to occur over a patient’s lifetime.
I believe that the best predictor of patient success isn’t as much whether they choose to have the banding versus the bypass, as it is the willingness of the patient to commit to:
(1) frequent follow-up with the surgeon, and
(2) making the lifestyle changes that are necessary to obtain the best results from their chosen surgery.
With that in mind, I feel that it is my job to fully inform my patients of the pros and cons of both the gastric bypass and the band, try to advise them as best as possible with the outcome statistics that are available, and having done so, we can both move forward as a team, committing fully to whichever operation is decided upon. I tell my patients very honestly that the gastric bypass indeed has a long and successful track record, but some patients, having heard and digested all the facts, prefer to sacrifice more initial weight loss in order to have an operation that carries less peri-operative risk and is adjustable over time.
The Nuts and Bolts of It
One of the most important things to know about the 5 year outcomes for the banding is that the surgery itself is considered extremely safe. There are, however, complications that can arise over time, such as development of a hiatal hernia with severe acid reflux, stomach dilation, band slippage and erosion into the stomach itself, all of which can be very severe and require another operation with band removal (this is called a reversal). The patient would, of course, be very likely re-gain the lost weight – and frequently more, after reversal.
Some myths have become quite prominent amongst the public – it is extremely important to make a decision knowing the facts and not base any decisions upon misinformation from internet chat rooms and the like.
A few of the things that you must fully understand when considering gastric banding are here:
The Simplicity of the Operation
The gastric banding is technically a simpler operation than the gastric bypass. There is no division of the stomach and no hook-up to the small intestine, as with the gastric bypass. Such hook-ups can leak and develop strictures, which is too much scarring. You can learn more about this complication in the section on gastric bypass complications.
The possible complications that a patient might encounter during or immediately following banding surgery (these are called “peri-operative” complications) are certainly less frequent than for the gastric bypass. However, one of the potential hazards of the band is that we don’t really know how often people are going to develop serious complications, like the ones listed above (erosion, slippage, etc), and might require surgery and band removal months or years down the line. Part of the reason that we can’t tell patients how often these things will happen is because the band is a relatively new technology and the band itself has been modified several times since FDA approval in 2001. These improvements have been designed to reduce these complications and this is generally felt to be the case, but the long term results aren’t available yet.
It appears that the risk of developing some of the serious complications (erosion, stomach dilation, hiatal hernia) with the band may actually increase over time. It has to be said however, that with close follow-up with your surgeon, these complications should be able to be diagnosed speedily and band removal, if necessary, can be performed while maintaining a very high level of patient safety.
Let’s address the issue of reversibility. One of the attractions of the band for many folks is that they know that it can be removed. This is, in and of itself, a good thing. It’s understandable that people fear change, even if it’s a “good change.” It’s human nature to want to have some sort of a safety net if things don’t work out the way we want them to. One of the problems with the marketing of the band is that some members of the public believe that the band is meant to be reversed – that it is designed to be removed after the desired weight loss is obtained. This is not true. It is designed to stay in place, acting as a tool for losing weight and maintaining weight loss. Experience shows us that if the band is removed, all of lost weight is usually rapidly re-gained. Bands are usually removed/reversed only due to complications or inadequate weight loss. In the case of inadequate weight loss, the operation is usually switched to a gastric bypass. This is called a revision. On the other hand, while the gastric bypass is also reversible, very few patients in the United States have had to undergo reversal of a gastric bypass, but just knowing that both operations are reversible may be useful information to people during the decision making process.
The issue of reversibility becomes a problem when a patient decides to have banding surgery, while thinking in the back of their mind “Well, I’ll give this a go, and if it doesn’t work out, I will just have it removed and I’ll be just like I was before.” There are a couple of very serious flaws in this reasoning:
First of all, in order to make any sort of weight loss surgery work in the long run, the patient has to be wholly committed to developing new habits and sticking with them. If someone says “I’ll marry this person, even though I’m not really sure it will work, because I can just get a divorce if I change my mind…” that’s someone who clearly hasn’t committed to the relationship and probably won’t work very hard to make the lifestyle adjustments that are necessary to create a strong marriage. It won’t be a surprise to anyone when the marriage doesn’t work. The same applies to having weight loss surgery. You have to be completely committed to making it work or you shouldn’t do it. The gastric band is only a tool, or an aid, to help you feel full quickly. It’s up to you to use it to your best advantage.
Secondly, what many folks don’t realize is that while the band is reversible, meaning that it can be removed from the body, the changes that occur in and around the stomach (dilation of the stomach leading to abnormal function of the stomach, scarring, and others) are often irreversible. Your body will never return to its normal, pre-surgery state after having any type of surgery, banding included.
The great majority of reversals occur because of complications with the band or due to inadequate weight loss, not because people simply “change their mind.” Most people who have the gastric banding reversed are able to have it converted to a gastric bypass, although undergoing a bypass after you’ve had a band is far riskier than not having had the band first. When you decide to have surgery, no matter what kind, you need to approach it as a decision for life.
The Success Rate of the Gastric Banding
“Success” is defined very differently for each patient, so it’s extremely important to me that I establish with every patient a very strong understanding of just what they want to achieve with weight loss surgery. Some patients want to be able to walk without pain and breathe comfortably, while others wish to live without diabetes, hypertension or sleep apnea. Some patients feel that if they could just lose 30 or 40 pounds of their excess weight, they would be happy and healthy, while others need to lose 100 or more pounds to achieve “success.” I aim to ensure that every patient of mine has set a realistic goal for themselves and that they have chosen the surgical tool that will best suit their needs and lifestyle.
Weight loss after gastric banding is much slower than the gastric bypass, often occurring over a period of 2-3 or more years. Research shows that patients who undergo gastric banding lose, on average, 30-40% of their excess body weight during the first year or so. If a patient desires very gradual weight loss, a band may become a good choice for them. The research shows that patients who are not diabetic and have BMI’s less than 50 at the time of surgery, who are dedicated to frequent follow-up visits and working with the program, might reach 50 or 60% of their excess body weight lost by 2 years after surgery and lose even more in the 3rd year. Some patients can achieve even better results with their weight loss, and as I have stated, their commitment to making the dietary and lifestyle changes is the best predictor of the extent of success. It’s important that every patient who is considering an operation of any kind understand the statistics so they can select the option that best suits their needs and lifestyle.
Research shows that weight related medical problems like hypertension, diabetes and sleep apnea can go away after gastric banding, but not quite as often as with the gastric bypass. These problems also take a longer period of time to resolve, partially because the weight loss is slower with the banding. Most patients experience improvement in their acid reflux after banding, but it is sometimes exacerbated by a band that is too tight, which is an important reason to have close and frequent follow-up with the surgeon. Some surgeons advocate not performing a gastric banding if the previous acid damage is very severe. A gastric banding may be an excellent choice for someone who doesn’t suffer from these problems. Knowing a patient’s medical condition in full is very helpful during conversations with my patients. A patient needs to know what to expect from an operation so they can choose the procedure that will best aid them in meeting their individual medical and weight loss goals.
A Very Individual Decision
There are many factors that play into deciding who might be a good candidate for a gastric banding. It isn’t possible to lay out the entire decision tree on a website, as much of the decision making emerges during discussions with each patient. I feel that it is my job to listen to my patients and understand their needs and expectations of weight loss surgery and share with them the details of their medical evaluation. Only then will I be able to conduct an honest discussion with my patients about the risks and benefits of all the options with respect to their specific circumstance. If a patient is a good candidate for weight loss surgery, and I know that they have made an educated and informed decision to undergo a certain operation, it becomes my job to support them in every way I can and work with them to achieve the best possible success.