Fad Bariatric Surgery Part 1: Laparoscopic Adjustable Gastric Band
There is no better example of a “fad” bariatric surgery than the simplest bariatric operation of all, the Laparoscopic Adjustable Gastric Band, which was approved for use in the United States by the FDA in 2001, after having been used in Europe since the 1980’s. It quickly became a popular operation among surgeons and the lay public for two main reasons, including the ease of the operation, which permitted general surgeons without bariatric surgery training or previous experience to perform the operation, and because of direct-to-consumer marketing by the band manufacturer, including TV commercials for the band.
However, since then, there have been numerous (probably hundreds) of medical journal reports indicating that the Gastric Band is inferior to the Gastric Bypass and (when it emerged recently), the Sleeve Gastrectomy, in terms of weight loss and resolution of comorbidities. It has long been known that the average weight loss after the Gastric Band is only 45-48% of excess body weight (which equals an individual’s current weight minus their ideal body weight, which is calculated based on their height). By contrast, Gastric Bypass patients lose an average of 80-85% and Sleeve Gastrectomy patients lose an average of 65-70% of their excess body weight within the first year.
To put this in perspective, for a height of 5′ 5″, the ideal body weight is 150 pounds. If a 5’5″ tall person weighs 300 pounds, they would have a BMI of 50 and an excess body weight of 150 pounds. If that person underwent a Gastric Band accompanied by its average weight loss, they would lose 48% of their excess body weight, or 72 pounds, leaving them at a weight of 228 pounds and a BMI of 38, still above the BMI threshold of 35 defining the disease of Severe Obesity. In other words, even though the Gastric Band was “successful” in achieving its average weight loss, the patient would still be left with the disease of Severe Obesity, accompanied by its attendant health risks. Therefore, in this regard, the Gastric Band failed, because it did not achieve for the patient a BMI of less than 35, or preferably close to or less than 30, which other bariatric operations would have achieved in this scenario, based on their average weight loss results. In other words, the Gastric Band did not adequately treat their disease of Severe Obesity for this hypothetical patient. The effectiveness of a particular bariatric operation should be measured, not just in terms of average excess body weight loss, but whether the operation accomplishes the goal of bringing the patient to a healthy weight and resolves the patient’s comorbidities. If the same patient had undergone a Gastric Bypass, they would have lost 120 pounds down to a resulting weight of 180 pounds with a BMI of 30.
Although a properly adjusted Gastric Band can cause a sensation of fullness after eating small volume meals, one reason for its relatively limited effectiveness is that, unlike Gastric Bypass and Sleeve Gastrectomy, the Gastric Band causes no fundamental effect on the hormonal mechanisms that lead to hunger in the first place. Therefore, patients continue to experience hunger, cravings and food temptations, just as they did before surgery, and their ability to resist unhealthy, high carbohydrate, high fat, high calorie foods, is dependent primarily on their own willpower, a situation no different than dieting. On the other hand, Gastric Bypass and Sleeve Gastrectomy are accompanied by a lengthy “honeymoon” period postoperatively, characterized by indifference to food; which, for the patient, can feel like being unburdened, relieved of the near-constant mindfulness of food that typically accompanies Severe Obesity.
Furthermore, several medical articles have been published in the past few years revealing that over follow-up periods of up to 15 years after surgery, the Gastric Band has a failure rate of up to 50% (with failure defined as the loss of less than 25% of excess body weight and/ or the occurrence of a complication of the band requiring its removal). Band removal is usually followed by weight gain (if the patient lost weight to begin with), which then necessitates conversion to a more effective bariatric operation, like Gastric Bypass or Sleeve Gastrectomy.
It is important to realize that if a documented complication of the Gastric Band occurs, the insurance payer will authorize band removal. However, the insurance payers do not recognize failure to lose weight or regaining weight as a “complication”, and in this situation, will generally not authorize band removal. Therefore, unless they can pay cash for band removal, the numerous patients with the Gastric Band who fail to lose weight or who regain weight are required to retain the ineffective band inside their bodies for the rest of their lives.
In addition, patients are often misinformed about the apparent “advantages” or success of the Gastric Band. For example, some people are attracted to the notion that the Gastric Band is “reversible”. However, “reversal” of the Gastric Band means removing it, which typically indicates that it has been unsuccessful or resulted in a complication which requires its removal, which is then accompanied by weight regain. The Gastric Band is also promoted as being “adjustable”. The truth is, the band must be adjusted in order to work, which requires frequent visits to the surgeon’s office; whereas the Gastric Bypass and Sleeve Gastrectomy do not require adjustment. They simply begin to work immediately after surgery.
Advocates of the Gastric Band also like to point out that, because the band does not require any division or connections of the stomach or intestine, it has the lowest short-term complication rate. Although this is true, the complication rates of Gastric Bypass and Sleeve Gastrectomy are very low as well, whereas the Gastric Band has, by far, the highest long-term complication rate and failure rate of any bariatric operation. It is the responsibility of the bariatric surgeon to correct these misconceptions and this misinformation when it exists, not to take advantage of it.
For these reasons, bariatric patients should not be advised that Gastric Band is the most favorable bariatric operation. In fact, many conscientious bariatric surgeons no longer offer Gastric Band to their patients and it is beginning to lose popularity among the lay public. However, despite all this, some bariatric surgeons still do recommend the Gastric Band, even as the first option, not because it is the best operation for the patient’s disease (which is not the case), but because it is the easiest and quickest bariatric operation for the surgeon to perform and can often be performed at an outpatient surgery center, with which the bariatric surgeon may have an ownership interest, enabling him/ her to recover not only a professional (surgeon’s) fee, but also a facility fee for the surgery, which can be very lucrative, especially if the surgery center is Out-of-Network for the particular patient’s commercial health insurance payer or for all insurance carriers. For the surgeon, this is immensely self-serving and creates a gross conflict of interest in terms of the surgeon’s unbiased medical decision making.
Check back to our blog soon to read part 2 of our series on bariatric surgeries that have become fads, despite not always being the ideal weight loss procedure for each patient.