Myth? Myth? Yes! Top 10 Myths About Laparoscopic Gastric Bands

by Jeff Allen, MD

Dr. Allen is Associate Professor of Surgery, University of Louisville, Louisville, Kentucky

Disclosures: Dr. Allen receives financial support for Karl Storz, Allergan Health, Ethicon Endosurgery, and Gore.

Introduction

I serve as surgeon, adjustor, proctor, and consultant for the Lap-Band® adjustable gastric band. In these jobs, one of the most important things that I do is answer questions about the device. These questions come from patients, other surgeons, nurses, and referring doctors, to name a few. In speaking to these people, I realize that there are a number of preconceived notions and misconceptions about gastric bands. The purpose of this article is to address and dispel myths about the Lap-Band®.

1. The bands don’t work.

Historically, there has been a division among bariatric surgeons over which operation is superior: Gastric band or gastric bypass. The gastric band typically has slower weight loss than the gastric bypass, but it is notably safer. While the
Lap-Band® was an overnight sensation in Europe, Latin America, and Australia, the initial studies in the United States were not impressive, with less than 40-percent excess weight loss (EWL). However, in time—with improvements in surgical technique and adjustment strategies— numerous American series have shown excellent weight loss, low morbidity, and very low mortality.[1–3] Furthermore, long-term results in some series have shown the Lap-Band® to be more successful than gastric bypass after five years.[4]

The division between the two operations is needless. Both gastric band and gastric bypass are reliable, effective, and safe. In addition, sleeve gastrectomy and duodenal switch (DDS) offer additional choices. While it may be difficult to predict which operation will be best for an individual patient, the bottom line is that most patients will greatly benefit from one of these operations.

2. The device is not appropriate for patients 17 years old or younger.

Bariatric surgery in teens and adolescents has always been a contentious issue. Because teens also are becoming overweight at an alarming rate, operative intervention is now becoming a feasible option for the morbidly obese patient who is less than 18 years of age. In the past, many surgeons have chosen to do gastric bypass on adolescents, but have increased the weight requirement above National Institute of Health guidelines (body mass index [BMI] above 50kg/m2, for example). Because most obese teenagers become morbidly obese adults, it appears that this logic is flawed, and perhaps the qualifying weight for surgery should actually be less than that of an adult.

Drs. Ren and Fielding have one of the largest initial American studies of using the Lap-Band® in adolescents.5 In this series, 53 patients ages 13 to 17 underwent gastric band surgery. The patients had an initial mean BMI of 47.6kg/m2 and lost 50 percent of their excess body weight at 18 months after surgery. The investigators found banding to be a safe and effective treatment of the morbidly obese adolescent.

The product insert of a Lap-Band® indicates that the device is intended for use in adults age 18 and over. Thus, placement in a patient under 18 years of age is considered off-label and may expose the bariatric surgeon, his or her team, and the hospital to additional liability risk in the event of a complication. For this reason, and because the usage of the device in an adolescent is still under study, it is recommended that the surgeon place gastric bands in patients under 18 years of age only as part of an Institutional Review Board-approved protocol.

3. They are contraindicated in the super-obese.

The management of patients with a BMI above 60kg/m2 (i.e., the super-obese) is also a controversial topic. In addition to gastric band, other options include the gastric bypass, biliopancreatic bypass or DDS, and sleeve resection. Because the band has a lower mortality rate than the other operations and these particular patients are more likely to have severe, cascading complications, I think it is an ideal fit. A recent study of 53 patients in America with a BMI greater than 60kg/m2 found that, at 18 months, these patients had lost 43 percent of their excess body weight.[6] The authors note that the super-obese will lose weight at a rate slower than patients with a lower BMI. All four of the surgical options for treating the super-obese patient appear to be successful. The benefit of the gastric band in this group is the decreased mortality rate.

4. Sweet eaters will not lose weight with a band.

The origination of this myth has roots with the vertical banded gastroplasty when compared with the gastric bypass.[7] The roux limb of a gastric bypass has the theoretical benefit of causing the dumping syndrome after ingestion of carbohydrates. This unpleasant phenomenon is negative reinforcement and may influence future sweet eating in the patient. In my experience, however, dumping syndrome severe enough to influence future eating behavior is uncommon.
It is difficult to determine who should be considered a sweet-eater. In truth, many patients enjoy eating sweets. Studies from Italy, Germany, and Australia have examined the role of sweet eating and weight loss after gastric banding. Each has shown no difference in weight loss with respect to sweet-eaters versus non-sweet-eaters.[8–10]

5. The band cannot be used in conjunction with gastric bypass.

A variety of hybrid operations have been proposed in the past that combine the restrictive properties of the band with the malabsorptive properties of the gastric bypass. When performed simultaneously, no significant benefit has been found over the respective operations individually. However, with greater frequency, gastric bands or gastric bypasses are being performed as “salvage” operations in patients with inadequate weight loss or recidivism. A gastric bypass after a band generally involves removing the band and construction of a stapled pouch. In essence, the gastric band is reversed.

Banding an existing bypass, however, doesn’t mean eliminating the beneficial effects of the Roux-en-Y configuration. Dr. Bessler from Columbia University was the first American to report results of a series of placing a Lap-Band® around a failed gastric bypass.[11] In their study, eight patients lost an average of 62 percent of their excess body weight after placement of the band over a bypass. The number of surgeons using the band in this capacity is increasing and, with experience, many of the fine points surrounding this technique will be answered. These include patient selection (large residual pouch only?), the role of plicating the band, and the anatomic location of the plication.

6. The band is filled up with air.

This is an easy one. An adjustment to the band is performed under aseptic conditions using sterile normal saline solution. In fact, the entire process of prepping the device on the back table during the operation is designed specifically to remove any air in the system. This is because air is infinitely more compressible than a liquid. A trip to the mountains or a scuba dive could cause drastic changes to the size of the band if it were filled with air. Normal saline is chosen because of its low cost, ubiquity, and lack of concentration gradient that could change volumes inside the device.

7. The band never slips or causes dilation.

The rate of eccentric gastric prolapse has markedly decreased with improvements and modifications in surgical technique.[12] Notably, the transition between the perigastric to pars flaccida technique has decreased the prolapse rate from 21 percent to one percent in Ponce’s series.[2] However, even with an optimal technique, gastric prolapse can still occur. This may be due to suture failure, inadequate plication, or patient nonadherence, among others. While the prolapse rate has improved, it has not been completely eliminated.

The frequency of gastric or esophageal dilation, on the other hand, has not been noted to have drastically changed since gastric bands first were placed. This phenomenon is thought to be due to over-tightening of the device, or initial placement too tight. Proponents of adjustments using a barium calibration meal will point out that dilation may be diminished with this method because the surgeon can see the problem early on and not tighten the device anymore.

Advocates of the non-X-ray adjustment method, on the other hand, will note that the barium study is costly, exposes the patient and staff to radiation, often requires a trip to the hospital, and may be less likely to be covered and/or reimbursed by third party insurers.

8. The adjustment port will set off an airport metal detector.

Although the sophistication and sensitivity of metal detectors will vary, a patient with a Lap-Band® (port) generally will not set off the walk-through screen. Remember, however, that the walk-through detectors establish the sum total of the metal passing through. A belt buckle, wristwatch, and a Lap-Band® adjustment port may be enough to cause an alarm. Further, a secondary screen with a wand will nearly always identify the port as a source of metal. For this reason, I recommend patients carry a card with them identifying themselves as a Lap-Band® patient. Having the card of the surgeon who placed the device can be handy as well.

9. An MRI cannot be done after banding.
There is no contraindication for magnetic resonance imaging (MRI) after Lap-Band®. The Lap-Band® is MRI-compatible.

10. Any surgeon will be glad to adjust a band placed outside the United States.

This is a myth that is propagated by foreign marketing. While surgeons understand the dilemma that patients face when trying to pay for a weight loss operation, most also realize the cost of doing business. Routinely assuming the care of a patient who needs an adjustment is certainly a benevolent gesture, but it increases risk without increasing reimbursement. Many patients do not understand the medical economics of a surgical practice. A surgeon who does not do the operation is not generating income. Further, adjusting the band may predispose the surgeon to liability associated with faulty initial placement of the device. Surgeons often choose not to adjust bands they didn’t place due to limited reimbursement and increased liability.

References
1. Watkins BM, Montgomery KF, Ahroni JH. Laparoscopic adjustable gastric banding: Early experience in 400 consecutive patients in the USA. Obes Surg 2005;15(1):82–7.
2. Ponce J, Paynter S, Fromm R. Laparoscopic adjustable gastric banding: 1,014 consecutive cases. J Am Coll Surg 2005;201(4):529–35.
3. Ren CJ, Weiner M, Allen JW. Favorable early results of gastric banding for morbid obesity: The American experience. Surg Endosc 2004;18(3):543–6.
4. O’Brien PE, Dixon, JB. Lap-band: Outcomes and results. J Laparoendosc Adv Surg Tech 2003;13:265–70.
5. Nadler EP, Youn HA, Ginsburg HB, et al. Short-term results in 53 US obese pediatric patients treated with laparoscopic adjustable gastric banding. J Pediatr Sur. 2007;42(1):137–41.
6. Myers JA, Sarker S, Shayani V. Treatment of massive super-obesity with laparoscopic adjustable gastric banding. Surg Obes Relat Dis 2006;2(1):37–40.
7. Sugerman HJ, DeMaria EJ, Kellum JM. Sweet eating is not a predictor of outcome after Lap-Band placement? Obes Surg 2003;13(3):468–9.
8. Busetto L, Segato G, De Marchi F, et al. Outcome predictors in morbidly obese recipients of an adjustable gastric band. Obes Surg 2002;12(1):83–92.
9. Hudson SM, Dixon JB, O’Brien PE. Sweet-eating is not a predictor of outcome after Lap-Band placement. Can we finally bury the myth? Obes Sur. 2002;12(6):789–94.
10. Korenkov M, Kneist W, Heintz A, Junginger T. Laparoscopic gastric banding as a universal method for the treatment of patients with morbid obesity. Obes Surg 2004;14(8):1123–7.
11. Bessler M, Daud A, DiGiorgi MF, et al. Adjustable gastric banding as a revisional bariatric procedure after failed gastric bypass. Obes Surg 2005;15(10):1443–8.
12. O’Brien PE, Dixon JB, Laurie C, Anderson M. A prospective randomized trial of placement of the laparoscopic adjustable gastric band: Comparison of the perigastric and pars flaccida pathways. Obes Surg 2005;15(6):820–6.

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